Provider Demographics
NPI:1730811167
Name:ESTRADA, MARTIN DANIEL
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:DANIEL
Last Name:ESTRADA
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 1:204 GILES AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:CALEXICO
Mailing Address - State:CA
Mailing Address - Zip Code:92231-3057
Mailing Address - Country:US
Mailing Address - Phone:760-675-4801
Mailing Address - Fax:
Practice Address - Street 1:204 GILES AVE APT 7
Practice Address - Street 2:
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-3057
Practice Address - Country:US
Practice Address - Phone:760-675-4801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst