Basic Information
| Provider Information | |||||||||
| NPI: | 1891947214 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARDEMA | ||||||||
| FirstName: | MARTA | ||||||||
| MiddleName: | BEATRIZ | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35114 MESA GRANDE DR | ||||||||
| Address2: | |||||||||
| City: | CALIMESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923201937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515223695 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1669 N E ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924054405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098866737 | ||||||||
| FaxNumber: | 9098813871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2008 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 103TC0700X | PSB94023870 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.