Healthcare Provider Details

I. General information

NPI: 1942559679
Provider Name (Legal Business Name): MR. FERNANDO ANTONIO MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23501 CINEMA DR STE 200
VALENCIA CA
91355-5430
US

IV. Provider business mailing address

10605 BALBOA BLVD STE. 100
GRANADA HILLS CA
91344-6342
US

V. Phone/Fax

Practice location:
  • Phone: 661-288-4800
  • Fax:
Mailing address:
  • Phone: 818-832-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW75522
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: