Provider Demographics
NPI:1639370109
Name:MARTINEZ, MARY JOY (BSW, CAC II)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JOY
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:BSW, CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 DARTMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-1755
Mailing Address - Country:US
Mailing Address - Phone:719-994-1308
Mailing Address - Fax:
Practice Address - Street 1:3470 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1520
Practice Address - Country:US
Practice Address - Phone:719-545-1181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4866101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)