Provider Demographics
NPI:1265442487
Name:MARTIN, JOHNNY (LISW)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:MARTIN
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 1:1900 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-5053
Mailing Address - Country:US
Mailing Address - Phone:505-437-7404
Mailing Address - Fax:505-439-2860
Practice Address - Street 1:1900 10TH ST
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5053
Practice Address - Country:US
Practice Address - Phone:505-437-7404
Practice Address - Fax:505-439-2860
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-32031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000H5737Medicaid