Healthcare Provider Details

I. General information

NPI: 1972229888
Provider Name (Legal Business Name): DESIREE DAWN MARTINEZ LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1227 N RAILROAD AVE STE C
ESPANOLA NM
87532-3159
US

IV. Provider business mailing address

PO BOX 1725
SANTA CRUZ NM
87567-1725
US

V. Phone/Fax

Practice location:
  • Phone: 505-747-8187
  • Fax: 505-747-8306
Mailing address:
  • Phone: 505-927-9220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2022-0753
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: