Provider Demographics
NPI:1275612442
Name:MARTIN-RODRIGUEZ, KELLEY D (LISW)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:D
Last Name:MARTIN-RODRIGUEZ
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:MS
Other - First Name:KELLEY
Other - Middle Name:D
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:914 N CANAL ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-5110
Mailing Address - Country:US
Mailing Address - Phone:575-885-4836
Mailing Address - Fax:575-887-9579
Practice Address - Street 1:914 N CANAL ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-5110
Practice Address - Country:US
Practice Address - Phone:575-885-4836
Practice Address - Fax:575-887-9579
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-055891041C0700X
NMI-068891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM48857823Medicaid