Provider Demographics
NPI:1073912465
Name:CHAVEZ, MARTINA
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 PEYTON RD
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-7794
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:436 PEYTON RD
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7794
Practice Address - Country:US
Practice Address - Phone:505-710-7106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-5585235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist