Provider Demographics
NPI:1093550410
Name:MARTINEZ, KAELI RHIANNON
Entity type:Individual
Prefix:
First Name:KAELI
Middle Name:RHIANNON
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 WILLOWCREST LN
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-6686
Mailing Address - Country:US
Mailing Address - Phone:909-262-4425
Mailing Address - Fax:
Practice Address - Street 1:1556 S SULTANA AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-4238
Practice Address - Country:US
Practice Address - Phone:909-418-6923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician