Provider Demographics
NPI:1942822366
Name:MARTINES, CARMEN REGINA (MA)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:REGINA
Last Name:MARTINES
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 48TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121-3209
Mailing Address - Country:US
Mailing Address - Phone:608-217-1689
Mailing Address - Fax:
Practice Address - Street 1:3150 18TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2074
Practice Address - Country:US
Practice Address - Phone:650-516-7107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-07
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107280106H00000X, 102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist