Provider Demographics
NPI:1538938824
Name:MARTINEZ, ALEXIS ALAN
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:ALAN
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 PALO ALTO CT
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-1142
Mailing Address - Country:US
Mailing Address - Phone:956-650-4594
Mailing Address - Fax:
Practice Address - Street 1:21 PALO ALTO CT
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-1142
Practice Address - Country:US
Practice Address - Phone:956-650-4594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-27
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94028055103T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty