Basic Information
| Provider Information | |||||||||
| NPI: | 1871907600 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | ALEXANDRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 622 E PROVIDENCIA AVE | ||||||||
| Address2: | APT J | ||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915012942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185688374 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 E FOOTHILL BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911073464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269933000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2014 | ||||||||
| LastUpdateDate: | 11/24/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.