Provider Demographics
NPI:1043962707
Name:MARTINEZ, ROSALBA C
Entity type:Individual
Prefix:
First Name:ROSALBA
Middle Name:C
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2644 30TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3051
Mailing Address - Country:US
Mailing Address - Phone:310-314-6200
Mailing Address - Fax:310-450-2024
Practice Address - Street 1:1334 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1706
Practice Address - Country:US
Practice Address - Phone:310-314-6200
Practice Address - Fax:310-450-2024
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12387101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)