Provider Demographics
NPI:1407271745
Name:MARTINEZ, BENITA
Entity Type:Individual
Prefix:
First Name:BENITA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S 312 JAGUAR DRIVE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507
Mailing Address - Country:US
Mailing Address - Phone:505-310-4746
Mailing Address - Fax:
Practice Address - Street 1:S 312 JAGUAR DRIVE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507
Practice Address - Country:US
Practice Address - Phone:505-310-4746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-24
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
NMCSA0203021103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor