Healthcare Provider Details

I. General information

NPI: 1053815704
Provider Name (Legal Business Name): VICTORIA MICHELLE MARTINEZ LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAGEBRUSH ST SW
ALBUQUERQUE NM
87105-3942
US

IV. Provider business mailing address

1 SAGEBRUSH ST SW
ALBUQUERQUE NM
87105-3942
US

V. Phone/Fax

Practice location:
  • Phone: 505-869-4487
  • Fax: 505-869-5489
Mailing address:
  • Phone: 505-869-5475
  • Fax: 505-869-5489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCBT-2023-0664
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: