Provider Demographics
NPI:1497939060
Name:MARTINEZ, GUADALUPE ROSA (LSAA)
Entity Type:Individual
Prefix:MRS
First Name:GUADALUPE
Middle Name:ROSA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6621 DONIPHAN DR STE G
Mailing Address - Street 2:
Mailing Address - City:CANUTILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79835-5005
Mailing Address - Country:US
Mailing Address - Phone:915-877-5100
Mailing Address - Fax:915-877-5107
Practice Address - Street 1:6621 DONIPHAN DR STE G
Practice Address - Street 2:
Practice Address - City:CANUTILLO
Practice Address - State:TX
Practice Address - Zip Code:79835-5005
Practice Address - Country:US
Practice Address - Phone:915-877-5100
Practice Address - Fax:915-877-5107
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0108821101YA0400X
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMVNM30451NIMedicaid