Provider Demographics
NPI:1710560701
Name:MARTINEZ, MIRANDA ADELITA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ADELITA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 4 BOX 5B
Mailing Address - Street 2:
Mailing Address - City:HERNANDEZ
Mailing Address - State:NM
Mailing Address - Zip Code:87537-9706
Mailing Address - Country:US
Mailing Address - Phone:505-423-0648
Mailing Address - Fax:
Practice Address - Street 1:1201 PARKWAY DR # B
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-7258
Practice Address - Country:US
Practice Address - Phone:505-508-0865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician