Provider Demographics
NPI:1538404579
Name:BALDERAS MARTINEZ, FABIOLA
Entity type:Individual
Prefix:
First Name:FABIOLA
Middle Name:
Last Name:BALDERAS 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 1:120 W CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-5913
Mailing Address - Country:US
Mailing Address - Phone:805-740-4555
Mailing Address - Fax:
Practice Address - Street 1:120 W CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-5913
Practice Address - Country:US
Practice Address - Phone:805-740-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112450106H00000X, 101YM0800X
171M00000X
CA148740106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health