Provider Demographics
NPI:1750824603
Name:MARTINEZ, GABRIELLA ALYSHA
Entity Type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:ALYSHA
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 1:957 CASCADE RD SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-4351
Mailing Address - Country:US
Mailing Address - Phone:505-264-1539
Mailing Address - Fax:
Practice Address - Street 1:3311 CANDELARIA RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1959
Practice Address - Country:US
Practice Address - Phone:505-225-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-27
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
NM1-21-53594103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other