Provider Demographics
NPI:1558628602
Name:MARTINEZ, MELISSA JEAN (LMSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:LMSW
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 2000
Mailing Address - Street 2:
Mailing Address - City:MORIARTY
Mailing Address - State:NM
Mailing Address - Zip Code:87035-2000
Mailing Address - Country:US
Mailing Address - Phone:505-832-5957
Mailing Address - Fax:
Practice Address - Street 1:200 CENTER STREET
Practice Address - Street 2:
Practice Address - City:MORIARTY
Practice Address - State:NM
Practice Address - Zip Code:87035
Practice Address - Country:US
Practice Address - Phone:505-832-5957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3496781041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM349678Medicaid