Provider Demographics
NPI:1235500091
Name:MARTIN, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MARTIN
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 1:762 CYPRESS ST # 107
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3505
Mailing Address - Country:US
Mailing Address - Phone:909-599-1227
Mailing Address - Fax:702-944-7846
Practice Address - Street 1:762 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773
Practice Address - Country:US
Practice Address - Phone:909-599-1227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89378101YM0800X
225C00000X
CA1111681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor