Provider Demographics
NPI:1548842081
Name:SHELLEY MARTIN, LICENSED MARRIAGE AND FAMILY THERAPIST, INC
Entity type:Organization
Organization Name:SHELLEY MARTIN, LICENSED MARRIAGE AND FAMILY THERAPIST, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LMFT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:661-303-6975
Mailing Address - Street 1:27120 EUCALYPTUS AVE STE G162
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-4543
Mailing Address - Country:US
Mailing Address - Phone:661-303-6975
Mailing Address - Fax:951-281-8741
Practice Address - Street 1:9220 HAVEN AVE STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-8551
Practice Address - Country:US
Practice Address - Phone:661-303-6975
Practice Address - Fax:951-242-8741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-24
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty