Provider Demographics
NPI:1639890890
Name:ERIVES, MARTIN JOSUE
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:JOSUE
Last Name:ERIVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 W AZTEC BLVD
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-1818
Mailing Address - Country:US
Mailing Address - Phone:505-334-9474
Mailing Address - Fax:
Practice Address - Street 1:1118 W AZTEC BLVD
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-1818
Practice Address - Country:US
Practice Address - Phone:505-334-9474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-202202421041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool