Provider Demographics
NPI:1972349405
Name:MARTINEZ, ANGELIQUE (RADT)
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 LINCOLN AVE APT 6206
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-3609
Mailing Address - Country:US
Mailing Address - Phone:657-767-5752
Mailing Address - Fax:
Practice Address - Street 1:12781 JOSEPHINE ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-4622
Practice Address - Country:US
Practice Address - Phone:657-251-0503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1488161122101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)