Healthcare Provider Details

I. General information

NPI: 1417566456
Provider Name (Legal Business Name): MELISSA NICOLLE MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 E 12TH ST
OAKLAND CA
94601-3424
US

IV. Provider business mailing address

1586 HELSINKI WAY
LIVERMORE CA
94550-6118
US

V. Phone/Fax

Practice location:
  • Phone: 510-269-9030
  • Fax:
Mailing address:
  • Phone: 925-922-1664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberASW81967
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110333
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberASW81967
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: