Healthcare Provider Details

I. General information

NPI: 1225183908
Provider Name (Legal Business Name): KEVIN ALAN MARTINEZ LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 11/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 N 10TH STREET
FORT SUMNER NM
88119-0349
US

IV. Provider business mailing address

PO BOX 349 546 NORTH 10TH ST
FORT SUMNER NM
88119-0349
US

V. Phone/Fax

Practice location:
  • Phone: 575-355-2420
  • Fax: 575-355-7894
Mailing address:
  • Phone: 575-355-2420
  • Fax: 575-355-7894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-08098
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: