Provider Demographics
NPI:1740727163
Name:MARTINEZ, ANYA NICHOLE (RBT)
Entity type:Individual
Prefix:
First Name:ANYA
Middle Name:NICHOLE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6612 FOUNTAIN RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-4712
Mailing Address - Country:US
Mailing Address - Phone:719-238-1449
Mailing Address - Fax:
Practice Address - Street 1:6612 FOUNTAIN RIDGE CIR
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-4712
Practice Address - Country:US
Practice Address - Phone:719-238-1449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician