Healthcare Provider Details

I. General information

NPI: 1790654440
Provider Name (Legal Business Name): ALEJANDRA MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2025
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 DOWNEY AVE
MODESTO CA
95354-1208
US

IV. Provider business mailing address

12117 WASHBURN AVE
WATERFORD CA
95386-9600
US

V. Phone/Fax

Practice location:
  • Phone: 209-341-1824
  • Fax:
Mailing address:
  • Phone: 209-356-8378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number141214
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: