Healthcare Provider Details

I. General information

NPI: 1053693432
Provider Name (Legal Business Name): RUTH MARIE MARTIN MFT INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15339 SATICOY ST
VAN NUYS CA
91406
US

IV. Provider business mailing address

15339 SATICOY ST
VAN NUYS CA
91406-3345
US

V. Phone/Fax

Practice location:
  • Phone: 818-267-2600
  • Fax:
Mailing address:
  • Phone: 818-267-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number107411
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: