Healthcare Provider Details

I. General information

NPI: 1184135634
Provider Name (Legal Business Name): MARTIN TATRO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 CARMEN LN
SANTA MARIA CA
93458-7769
US

IV. Provider business mailing address

212 CARMEN LN
SANTA MARIA CA
93458-7769
US

V. Phone/Fax

Practice location:
  • Phone: 805-212-7680
  • Fax: 805-728-9492
Mailing address:
  • Phone: 805-212-7680
  • Fax: 805-728-9492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: