Healthcare Provider Details

I. General information

NPI: 1487796074
Provider Name (Legal Business Name): MARIA R. MARTIN PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W FOOTHILL BLVD STE 104
SAN DIMAS CA
91773-1170
US

IV. Provider business mailing address

100 W FOOTHILL BLVD STE 104
SAN DIMAS CA
91773-1170
US

V. Phone/Fax

Practice location:
  • Phone: 909-519-2662
  • Fax: 909-575-4528
Mailing address:
  • Phone: 909-519-2662
  • Fax: 909-575-4528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 36100
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY27160
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: