Healthcare Provider Details

I. General information

NPI: 1891310645
Provider Name (Legal Business Name): LOUIE JOHN MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2020
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 S E ST STE 250
SAN BERNARDINO CA
92408-2706
US

IV. Provider business mailing address

4269 MOUNTAIN DR
SAN BERNARDINO CA
92407-3009
US

V. Phone/Fax

Practice location:
  • Phone: 909-433-9300
  • Fax: 909-433-9308
Mailing address:
  • Phone: 909-648-1971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW100308
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW100308
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number120065
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: