Healthcare Provider Details

I. General information

NPI: 1164189288
Provider Name (Legal Business Name): GLORIA MARTINEZ LCPC, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2021
Last Update Date: 09/28/2024
Certification Date: 09/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12004 N STAR TRL NW
ALBUQUERQUE NM
87120-5042
US

IV. Provider business mailing address

8023 CARPENTER CREEK AVE
LAS VEGAS NV
89113-3685
US

V. Phone/Fax

Practice location:
  • Phone: 505-450-7115
  • Fax:
Mailing address:
  • Phone: 505-450-7115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCP3322-R
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH0185541
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: