MEDICARE: MS. CAROL R MARTINEZ LADAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	3643	NM

General Provider Information

NPI Number	:	1235362732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROL R MARTINEZ LADAC

Provider Business Mailing Address
First Line	:	612 N PASEO DE ONATE
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2963
Country	:	US
Telephone Number	:	505-753-2203
Fax Number	:	505-747-1881

Provider Business Practice Location Address
First Line	:	612 N PASEO DE ONATE
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2963
Country	:	US
Telephone Number	:	505-753-2203
Fax Number	:	505-747-1881

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2009
Last Update Date	:	09/02/2009

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