Healthcare Provider Details

I. General information

NPI: 1578031621
Provider Name (Legal Business Name): CRYSTAL MARTINEZ BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2018
Last Update Date: 05/29/2023
Certification Date: 05/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CONCORD AVE STE 100
CONCORD CA
94520-4969
US

IV. Provider business mailing address

4221 WILSHIRE BLVD STE 300A
LOS ANGELES CA
90010-3537
US

V. Phone/Fax

Practice location:
  • Phone: 877-910-6538
  • Fax:
Mailing address:
  • Phone: 888-428-3223
  • Fax: 323-556-3048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-35197
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: