Healthcare Provider Details

I. General information

NPI: 1457892994
Provider Name (Legal Business Name): ANSBERTO MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2017
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4323 W RIVERSIDE DR
BURBANK CA
91505-4044
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-301-7396
  • Fax: 310-828-5165
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number127032
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: