Healthcare Provider Details

I. General information

NPI: 1134982770
Provider Name (Legal Business Name): KIMBERLY MARTIN PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 DEL NORTE RD STE 200
CAMARILLO CA
93010-8368
US

IV. Provider business mailing address

210 E PLEASANT VALLEY RD
PORT HUENEME CA
93041-2745
US

V. Phone/Fax

Practice location:
  • Phone: 805-813-1659
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPSY34834
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY34834
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number176124V
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: