Provider Demographics
NPI:1174836944
Name:MARTINEZ, CRYSTAL (MS BCBA)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MS BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 POETS SQ
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-6004
Mailing Address - Country:US
Mailing Address - Phone:619-578-9958
Mailing Address - Fax:
Practice Address - Street 1:429 POETS SQ
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-6004
Practice Address - Country:US
Practice Address - Phone:619-578-9958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-09-5840103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst