Provider Demographics
NPI:1346762192
Name:VALDEZ, CRISTAL MARTINEZ (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CRISTAL
Middle Name:MARTINEZ
Last Name:VALDEZ
Suffix:
Gender:F
Credentials:MS, CCC-SLP
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 1106
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:NM
Mailing Address - Zip Code:87567-1106
Mailing Address - Country:US
Mailing Address - Phone:505-927-1045
Mailing Address - Fax:505-753-1219
Practice Address - Street 1:708 LA JOYA STREET
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2877
Practice Address - Country:US
Practice Address - Phone:505-753-6550
Practice Address - Fax:505-753-1219
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3628235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3628OtherPROFESSIONAL LICENSE NUMBER