Healthcare Provider Details

I. General information

NPI: 1124438460
Provider Name (Legal Business Name): PRISMA MARTINEZ M.S., LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 E LOS ANGELES AVE STE 237
SIMI VALLEY CA
93065-5829
US

IV. Provider business mailing address

PO BOX 1716
SIMI VALLEY CA
93062-1716
US

V. Phone/Fax

Practice location:
  • Phone: 818-743-6517
  • Fax:
Mailing address:
  • Phone: 818-743-6517
  • Fax: 818-626-5056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number111896
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: