Healthcare Provider Details

I. General information

NPI: 1558881862
Provider Name (Legal Business Name): DIANNA CHRISTINE MARTINEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 BROADWAY
SAN DIEGO CA
92101-5710
US

IV. Provider business mailing address

PO BOX 421141
SAN DIEGO CA
92142-1141
US

V. Phone/Fax

Practice location:
  • Phone: 619-276-8112
  • Fax:
Mailing address:
  • Phone: 619-276-8112
  • Fax: 619-276-8230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number77394
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: