Healthcare Provider Details

I. General information

NPI: 1972824019
Provider Name (Legal Business Name): PATRICK VINCENT MARTIN MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1359 N GRAND AVE
COVINA CA
91724-1016
US

IV. Provider business mailing address

1359 N GRAND AVE
COVINA CA
91724-1016
US

V. Phone/Fax

Practice location:
  • Phone: 626-430-2900
  • Fax: 626-331-0035
Mailing address:
  • Phone: 626-430-2900
  • Fax: 626-331-0035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number31065
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number65608
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: