Healthcare Provider Details

I. General information

NPI: 1659010213
Provider Name (Legal Business Name): KEYSHA ANN MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KEYSHA ANN MARTINEZ

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1257 SW 4TH AVE
ONTARIO OR
97914-4516
US

IV. Provider business mailing address

379 VAQUERO DR
ONTARIO OR
97914-8443
US

V. Phone/Fax

Practice location:
  • Phone: 154-188-9916
  • Fax:
Mailing address:
  • Phone: 208-420-0585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: