MEDICARE: STEPHANIE ELIZABETH MARTINEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1164948519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE ELIZABETH MARTINEZ

Provider Business Mailing Address
First Line	:	18943 DAMASCO ST
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91792-3038
Country	:	US
Telephone Number	:	626-643-6557
Fax Number	:

Provider Business Practice Location Address
First Line	:	1520 N RAYMOND AVE
Second Line	:	BLDG 2-7
City	:	PASADENA
State	:	CA
Zip	:	91103-9110
Country	:	US
Telephone Number	:	626-396-5920
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2017
Last Update Date	:	02/25/2021

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