Basic Information
| Provider Information | |||||||||
| NPI: | 1659672558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | VINCENT | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1436 | ||||||||
| Address2: | |||||||||
| City: | MARINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939331436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316785500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 31625 HIGHWAY 101 S | ||||||||
| Address2: | |||||||||
| City: | SOLEDAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939609529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316785500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2010 | ||||||||
| LastUpdateDate: | 05/17/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 67017 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | LCSW67017 | 01 | CA | BOARD OF BEHAVIORAL SCIENCE | OTHER | 28296 | 01 | ASOCIATE SOCIAL WORKER | OTHER |