Provider Demographics
NPI:1104150242
Name:MARTINEZ, ROSELLA G (SAA)
Entity type:Individual
Prefix:MRS
First Name:ROSELLA
Middle Name:G
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:SAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:GALLINA CANYON ROAD
Mailing Address - Street 2:HOUSE #12
Mailing Address - City:VALDEZ
Mailing Address - State:NM
Mailing Address - Zip Code:87580
Mailing Address - Country:US
Mailing Address - Phone:575-776-8009
Mailing Address - Fax:
Practice Address - Street 1:413 SIPAPU ST
Practice Address - Street 2:BOX 6952
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6489
Practice Address - Country:US
Practice Address - Phone:575-758-5758
Practice Address - Fax:575-758-2832
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0111351101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator