MEDICARE: CONNIE MARTIN MA

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	106H00000X	Marriage & Family Therapist	MFC 51365	CA

General Provider Information

NPI Number	:	1730245648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNIE MARTIN MA

Provider Business Mailing Address
First Line	:	4565 RUFFNER ST STE 110
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-2258
Country	:	US
Telephone Number	:	619-840-4898
Fax Number	:

Provider Business Practice Location Address
First Line	:	4565 RUFFNER ST STE 110
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-2258
Country	:	US
Telephone Number	:	619-840-4898
Fax Number	:

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

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	06/01/2012

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Directions to “ CONNIE MARTIN MA” Practice Location

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