Provider Demographics
NPI:1346392198
Name:MARTINEZ-CANDELARIA, RENEE (SW)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:MARTINEZ-CANDELARIA
Suffix:
Gender:F
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 ELLISON DR NW
Mailing Address - Street 2:CIBOLA HS
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5101
Mailing Address - Country:US
Mailing Address - Phone:505-897-0110
Mailing Address - Fax:
Practice Address - Street 1:1510 ELLISON DR NW
Practice Address - Street 2:CIBOLA HS
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5101
Practice Address - Country:US
Practice Address - Phone:505-897-0110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM 046921041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM74189751Medicaid