Basic Information
| Provider Information | |||||||||
| NPI: | 1174835409 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | TERI | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15095 AMARGOSA RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923941879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602454695 | ||||||||
| FaxNumber: | 7605134676 | ||||||||
| Practice Location | |||||||||
| Address1: | 15095 AMARGOSA RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923941879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602454695 | ||||||||
| FaxNumber: | 7605134676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2010 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | LCSW101451 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.