Provider Demographics
NPI:1336764430
Name:MARTINEZ, ANDREA ANAHI
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:ANAHI
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:PO BOX 1341
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-0827
Mailing Address - Country:US
Mailing Address - Phone:714-396-4074
Mailing Address - Fax:
Practice Address - Street 1:17053 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3574
Practice Address - Country:US
Practice Address - Phone:909-347-1300
Practice Address - Fax:909-347-1302
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW109658101YM0800X, 104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20160500162100Medicaid