Provider Demographics
NPI:1124292024
Name:MARTIN, RICKY ANTHONY (RRW)
Entity type:Individual
Prefix:MR
First Name:RICKY
Middle Name:ANTHONY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:RRW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 FLEMING AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95127-3610
Mailing Address - Country:US
Mailing Address - Phone:408-259-6565
Mailing Address - Fax:
Practice Address - Street 1:1281 FLEMING AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95127-3610
Practice Address - Country:US
Practice Address - Phone:408-259-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARW1183101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor