Healthcare Provider Details

I. General information

NPI: 1164073680
Provider Name (Legal Business Name): MARTENA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 E CHAPEL ST
SANTA MARIA CA
93454-4520
US

IV. Provider business mailing address

127 N J ST
LOMPOC CA
93436-6742
US

V. Phone/Fax

Practice location:
  • Phone: 895-925-8860
  • Fax:
Mailing address:
  • Phone: 760-459-9790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number133052
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: