Provider Demographics
NPI:1932923208
Name:MARTINEZ, BIANCA ROSALIA (LSAA)
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:ROSALIA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 YORK AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6790
Mailing Address - Country:US
Mailing Address - Phone:505-716-7967
Mailing Address - Fax:
Practice Address - Street 1:607 E APACHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6925
Practice Address - Country:US
Practice Address - Phone:505-326-2012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-13
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2024-0631101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)