Provider Demographics
NPI:1588124291
Name:MARTINEZ, RANDY
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2043 SAN FRANCISCO AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-4146
Mailing Address - Country:US
Mailing Address - Phone:562-889-4256
Mailing Address - Fax:
Practice Address - Street 1:10568 MAGNOLIA AVE STE 102
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-5864
Practice Address - Country:US
Practice Address - Phone:562-889-4256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TC1900X, 103TP0814X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis