Healthcare Provider Details

I. General information

NPI: 1518956291
Provider Name (Legal Business Name): PAMELA ANN MARTIN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 CALLE DE PANZA NW
ALBUQUERQUE NM
87104-3071
US

IV. Provider business mailing address

2405 CALLE DE PANZA NW
ALBUQUERQUE NM
87104-3071
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-6672
  • Fax:
Mailing address:
  • Phone: 505-242-6672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number241
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: