Healthcare Provider Details

I. General information

NPI: 1598477630
Provider Name (Legal Business Name): ANTHONY RENEE MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2022
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78140 CALLE TAMPICO
LA QUINTA CA
92253-2900
US

IV. Provider business mailing address

78140 CALLE TAMPICO
LA QUINTA CA
92253-2900
US

V. Phone/Fax

Practice location:
  • Phone: 760-619-6667
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number165495
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: