Basic Information
| Provider Information | |||||||||
| NPI: | 1942559679 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | FERNANDO | ||||||||
| MiddleName: | ANTONIO | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10605 BALBOA BLVD | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | GRANADA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913446342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188322400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 23501 CINEMA DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | VALENCIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913555430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612884800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2012 | ||||||||
| LastUpdateDate: | 02/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1041C0700X | LCSW75522 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.