Provider Demographics
NPI:1518479336
Name:YAZZIE-MARTIN, CHANTELLE TRISTA (LCSW)
Entity Type:Individual
Prefix:
First Name:CHANTELLE
Middle Name:TRISTA
Last Name:YAZZIE-MARTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S MAIN ST STE 249
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1243
Mailing Address - Country:US
Mailing Address - Phone:575-527-5823
Mailing Address - Fax:575-527-5886
Practice Address - Street 1:505 S MAIN ST STE 249
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1243
Practice Address - Country:US
Practice Address - Phone:575-527-5823
Practice Address - Fax:575-527-5886
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-096461041S0200X
NMSWB-2022-09511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool