Provider Demographics
NPI:1487796074
Name:MARTIN, MARIA R (PHD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:R
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W FOOTHILL BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1170
Mailing Address - Country:US
Mailing Address - Phone:909-519-2662
Mailing Address - Fax:909-575-4528
Practice Address - Street 1:100 W FOOTHILL BLVD STE 104
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1170
Practice Address - Country:US
Practice Address - Phone:909-519-2662
Practice Address - Fax:909-575-4528
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 36100106H00000X
CAPSY27160103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist