Healthcare Provider Details

I. General information

NPI: 1831757327
Provider Name (Legal Business Name): SAMANTHA NICOLE MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5051 CANYON CREST DR STE 204
RIVERSIDE CA
92507-6035
US

IV. Provider business mailing address

10500 SHERMAN GROVE AVE APT 204
SUNLAND CA
91040-3407
US

V. Phone/Fax

Practice location:
  • Phone: 951-682-1488
  • Fax:
Mailing address:
  • Phone: 818-276-5095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number33215
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: