Healthcare Provider Details

I. General information

NPI: 1225727688
Provider Name (Legal Business Name): SARA MARIE MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 05/02/2023
Certification Date: 04/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2772 SOUTH MARTIN LUTHER KING JR BLVD
FRESNO CA
93722
US

IV. Provider business mailing address

2772 SOUTH MARTIN LUTHER KING JR. BLVD
FRESNO CA
93722
US

V. Phone/Fax

Practice location:
  • Phone: 559-265-4818
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14813
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: