Healthcare Provider Details

I. General information

NPI: 1437713062
Provider Name (Legal Business Name): MARTIN ANCONA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 ANTHONY DR
ANTHONY NM
88021-9366
US

IV. Provider business mailing address

224 ANTHONY DR
ANTHONY NM
88021-9366
US

V. Phone/Fax

Practice location:
  • Phone: 214-662-1791
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MARTIN ANCONA
Title or Position: PH.D
Credential:
Phone: 214-662-1791