Basic Information
| Provider Information | |||||||||
| NPI: | 1336706001 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | MIKAYLA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 DURANT AVE APT 117 | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947041502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106842138 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8801 FOLSOM BLVD STE 195 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958263231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163824447 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2019 | ||||||||
| LastUpdateDate: | 05/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.