Provider Demographics
NPI:1588938997
Name:MARTINEZ, SUSANA SANTIAGO
Entity type:Individual
Prefix:MRS
First Name:SUSANA
Middle Name:SANTIAGO
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 1:1400 S GRAND AVE
Mailing Address - Street 2:600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3048
Mailing Address - Country:US
Mailing Address - Phone:213-742-6250
Mailing Address - Fax:
Practice Address - Street 1:1400 S GRAND AVE
Practice Address - Street 2:600
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3048
Practice Address - Country:US
Practice Address - Phone:213-742-6250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
CAD4326641101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional