Basic Information
| Provider Information | |||||||||
| NPI: | 1124202817 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | CCDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11900 AVALON BLVD STE 200 | ||||||||
| Address2: | 1 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900612867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232420500 | ||||||||
| FaxNumber: | 3232420600 | ||||||||
| Practice Location | |||||||||
| Address1: | 11900 S. AVALON BLVD | ||||||||
| Address2: | 1 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232420500 | ||||||||
| FaxNumber: | 3232420600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2007 | ||||||||
| LastUpdateDate: | 09/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | P122 | 01 | CA | P122 | OTHER |