Provider Demographics
NPI:1841188307
Name:DIAZ DE LEON MARTINEZ, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:DIAZ DE LEON 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 1:1075 MADDEN AVE APT C
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-2179
Mailing Address - Country:US
Mailing Address - Phone:619-832-9373
Mailing Address - Fax:
Practice Address - Street 1:489 E ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2445
Practice Address - Country:US
Practice Address - Phone:619-349-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-25
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst