Basic Information
| Provider Information | |||||||||
| NPI: | 1780854307 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | REY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1622 7TH ST | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 877014920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054548265 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5213 JAGUAR DRIVE | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058200262 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2008 | ||||||||
| LastUpdateDate: | 03/11/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | M - 05343 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.