Provider Demographics
NPI:1194966325
Name:MARTIN, MICHELE DIANE (PSY D, MS, LMFT)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:DIANE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PSY D, MS, LMFT
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:DIANE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:12277 APPLE VALLEY RD # 312
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-1701
Mailing Address - Country:US
Mailing Address - Phone:760-885-5410
Mailing Address - Fax:
Practice Address - Street 1:18484 OUTER HWY 18 STE 125
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307
Practice Address - Country:US
Practice Address - Phone:760-885-5410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-18
Last Update Date:2018-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31670106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist