Provider Demographics
NPI:1124617212
Name:EVANS, MARTINE MOLLIN (LMFT)
Entity type:Individual
Prefix:
First Name:MARTINE
Middle Name:MOLLIN
Last Name:EVANS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21531 VIA INVIERNO
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2636
Mailing Address - Country:US
Mailing Address - Phone:949-463-0513
Mailing Address - Fax:
Practice Address - Street 1:21531 VIA INVIERNO
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2636
Practice Address - Country:US
Practice Address - Phone:492-976-9189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101426101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health