Provider Demographics
NPI:1588337836
Name:MARTELL, MARY-ELLOUISE
Entity type:Individual
Prefix:
First Name:MARY-ELLOUISE
Middle Name:
Last Name:MARTELL
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 1:2201 KILSON DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92707-2954
Mailing Address - Country:US
Mailing Address - Phone:949-772-4447
Mailing Address - Fax:
Practice Address - Street 1:2201 KILSON DR
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92707-2954
Practice Address - Country:US
Practice Address - Phone:949-687-5529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1234341016101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)