Provider Demographics
NPI:1881182830
Name:MARTINEZ, MANUEL ROMAN I (CAC 1)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:ROMAN
Last Name:MARTINEZ
Suffix:I
Gender:M
Credentials:CAC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 GLENWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2213
Mailing Address - Country:US
Mailing Address - Phone:719-248-9629
Mailing Address - Fax:
Practice Address - Street 1:720 N MAIN ST STE 240
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3046
Practice Address - Country:US
Practice Address - Phone:719-569-7909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0007634101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)