Healthcare Provider Details

I. General information

NPI: 1447671581
Provider Name (Legal Business Name): REBECCA MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2013
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 E SHIELDS AVE
FRESNO CA
93726-7029
US

IV. Provider business mailing address

1839 S EL DORADO ST STE B
STOCKTON CA
95206-2025
US

V. Phone/Fax

Practice location:
  • Phone: 559-229-9040
  • Fax:
Mailing address:
  • Phone: 209-463-0872
  • Fax: 209-463-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: