Healthcare Provider Details

I. General information

NPI: 1972902435
Provider Name (Legal Business Name): AMBER MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2014
Last Update Date: 02/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5905 SOQUEL DR STE 600
SOQUEL CA
95073-2861
US

IV. Provider business mailing address

719 CAPITOLA AVE APT A
CAPITOLA CA
95010-2773
US

V. Phone/Fax

Practice location:
  • Phone: 626-234-5113
  • Fax:
Mailing address:
  • Phone: 626-234-5113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number104655
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: