Provider Demographics
NPI:1881862654
Name:MARTINEZ, SANDRA (PHD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1063
Mailing Address - Street 2:
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-1063
Mailing Address - Country:US
Mailing Address - Phone:575-824-9000
Mailing Address - Fax:
Practice Address - Street 1:101 LIVINGSTON LOOP STE C1
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9753
Practice Address - Country:US
Practice Address - Phone:575-824-9000
Practice Address - Fax:866-232-9241
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
NM0059C103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM73721760Medicaid