Healthcare Provider Details

I. General information

NPI: 1700166519
Provider Name (Legal Business Name): ENRIQUE MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2011
Last Update Date: 10/04/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1627 S HARGRAVE ST
BANNING CA
92220-6169
US

IV. Provider business mailing address

10 W BAY STATE ST UNIT 6724
ALHAMBRA CA
91802-2892
US

V. Phone/Fax

Practice location:
  • Phone: 951-922-7612
  • Fax:
Mailing address:
  • Phone: 951-955-3510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number82990
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: