1194966325 NPI number — MICHELE DIANE MARTIN PSY D, MS, LMFT

Table of content: MICHELE DIANE MARTIN PSY D, MS, LMFT (NPI 1194966325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194966325 NPI number — MICHELE DIANE MARTIN PSY D, MS, LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
MICHELE
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSY D, MS, LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARTIN
Provider Other First Name:
MICHELE
Provider Other Middle Name:
DIANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMFT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1194966325
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12277 APPLE VALLEY RD # 312
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APPLE VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92308-1701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-885-5410
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18484 OUTER HWY 18 STE 125
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-885-5410
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/18/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  31670 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)