Provider Demographics
NPI:1457422677
Name:MARTINEZ, TERESA MIA (MA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:MIA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5714 QUAY DR NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-5157
Mailing Address - Country:US
Mailing Address - Phone:505-681-9942
Mailing Address - Fax:
Practice Address - Street 1:1800 OLD PECOS TRL STE G
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4759
Practice Address - Country:US
Practice Address - Phone:505-954-9940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4023235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist