Healthcare Provider Details

I. General information

NPI: 1881955441
Provider Name (Legal Business Name): MS. MARTHA SERVIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 05/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11741 TELEGRAPH RD
SANTA FE SPRINGS CA
90670-3681
US

IV. Provider business mailing address

3181 W MONROE AVE
ANAHEIM CA
92801-6035
US

V. Phone/Fax

Practice location:
  • Phone: 562-801-0318
  • Fax:
Mailing address:
  • Phone: 714-932-1860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT36443
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: