Provider Demographics
NPI:1972229888
Name:MARTINEZ, DESIREE DAWN (LSAA)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:DAWN
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:PO BOX 1725
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:NM
Mailing Address - Zip Code:87567-1725
Mailing Address - Country:US
Mailing Address - Phone:505-927-9220
Mailing Address - Fax:
Practice Address - Street 1:1227 N RAILROAD AVE STE C
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3159
Practice Address - Country:US
Practice Address - Phone:505-747-8187
Practice Address - Fax:505-747-8306
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2022-0753101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMCTB-2022-0753Medicaid