Provider Demographics
NPI:1730759564
Name:MARTIN, MARIA TERESA (LICENSED MFT)
Entity type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:TERESA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LICENSED MFT
Other - Prefix:MISS
Other - First Name:MARIA
Other - Middle Name:TERESA
Other - Last Name:COLIMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30240 RANCHO VIEJO RD
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-1515
Mailing Address - Country:US
Mailing Address - Phone:714-726-8212
Mailing Address - Fax:
Practice Address - Street 1:30240 RANCHO VIEJO RD
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1515
Practice Address - Country:US
Practice Address - Phone:714-726-8212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT119836106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist