Provider Demographics
NPI:1518291558
Name:MARTINEZ, MARK (LADAC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:LADAC
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 339
Mailing Address - Street 2:C/O ZUNI RECOVERY CENTER
Mailing Address - City:ZUNI
Mailing Address - State:NM
Mailing Address - Zip Code:87327-0339
Mailing Address - Country:US
Mailing Address - Phone:505-782-4710
Mailing Address - Fax:505-782-5880
Practice Address - Street 1:101 'D' AVENUE
Practice Address - Street 2:BLACK ROCK
Practice Address - City:ZUNI
Practice Address - State:NM
Practice Address - Zip Code:87327-0101
Practice Address - Country:US
Practice Address - Phone:505-782-4710
Practice Address - Fax:505-782-5880
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM006263101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM70702713Medicaid