Provider Demographics
NPI:1285622498
Name:REZA, MARTHA RUTH (PH D)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:RUTH
Last Name:REZA
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280454
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91328-0454
Mailing Address - Country:US
Mailing Address - Phone:818-248-3413
Mailing Address - Fax:
Practice Address - Street 1:9010 RESEDA BLVD
Practice Address - Street 2:SUITE 217
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-3921
Practice Address - Country:US
Practice Address - Phone:818-248-3413
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 13272103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical