Healthcare Provider Details

I. General information

NPI: 1316859457
Provider Name (Legal Business Name): MYA NICOLE MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 S PRAIRIE AVE
PUEBLO CO
81005-2307
US

IV. Provider business mailing address

127 W BLAKELAND DR
PUEBLO CO
81007-6339
US

V. Phone/Fax

Practice location:
  • Phone: 719-569-4411
  • Fax:
Mailing address:
  • Phone: 719-821-4908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: