Healthcare Provider Details

I. General information

NPI: 1033765912
Provider Name (Legal Business Name): IVONNE GUADALUPE MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 06/29/2024
Certification Date: 06/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 W KATELLA AVE STE 150
ORANGE CA
92867-3432
US

IV. Provider business mailing address

PO BOX 1295
LOS ALAMITOS CA
90720-1295
US

V. Phone/Fax

Practice location:
  • Phone: 714-399-3480
  • Fax:
Mailing address:
  • Phone: 562-607-8566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: