Healthcare Provider Details

I. General information

NPI: 1154565604
Provider Name (Legal Business Name): JUAN MARTINEZ MFTI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 08/14/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N BLACKSTONE AVE
FRESNO CA
93701-1939
US

IV. Provider business mailing address

3520 E SHIELDS AVE STE 102
FRESNO CA
93726-6923
US

V. Phone/Fax

Practice location:
  • Phone: 559-538-1230
  • Fax:
Mailing address:
  • Phone: 559-538-1230
  • Fax: 559-591-6684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number63380
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number132143
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: