Provider Demographics
NPI:1992208839
Name:MARTINEZ, MELANIE RENAE
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:RENAE
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 1:1512 S KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-5410
Mailing Address - Country:US
Mailing Address - Phone:575-420-2114
Mailing Address - Fax:
Practice Address - Street 1:1512 S KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-5410
Practice Address - Country:US
Practice Address - Phone:575-420-2114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician