Provider Demographics
NPI:1225183908
Name:MARTINEZ, KEVIN ALAN (LISW)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ALAN
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 349
Mailing Address - Street 2:546 NORTH 10TH ST
Mailing Address - City:FORT SUMNER
Mailing Address - State:NM
Mailing Address - Zip Code:88119-0349
Mailing Address - Country:US
Mailing Address - Phone:575-355-2420
Mailing Address - Fax:575-355-7894
Practice Address - Street 1:546 N 10TH STREET
Practice Address - Street 2:
Practice Address - City:FORT SUMNER
Practice Address - State:NM
Practice Address - Zip Code:88119-0349
Practice Address - Country:US
Practice Address - Phone:575-355-2420
Practice Address - Fax:575-355-7894
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-080981041C0700X
NMI 45241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM74705075Medicaid