Healthcare Provider Details

I. General information

NPI: 1528764826
Provider Name (Legal Business Name): TRACI ELAINE MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 08/26/2023
Certification Date: 08/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 MYERS ST BLDG 3
RIVERSIDE CA
92503-5527
US

IV. Provider business mailing address

PO BOX 7234
SAN BERNARDINO CA
92411-0234
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4850
  • Fax: 951-358-4852
Mailing address:
  • Phone: 909-557-3102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT140908
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: