Healthcare Provider Details

I. General information

NPI: 1679294599
Provider Name (Legal Business Name): FABIOLA NAHIR MARTINEZ-PESANTE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2022
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3655 RUFFIN RD STE 260
SAN DIEGO CA
92123-1860
US

IV. Provider business mailing address

3655 RUFFIN RD STE 260
SAN DIEGO CA
92123-1860
US

V. Phone/Fax

Practice location:
  • Phone: 858-349-8745
  • Fax:
Mailing address:
  • Phone: 858-349-8745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number36415
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: