Healthcare Provider Details

I. General information

NPI: 1700614831
Provider Name (Legal Business Name): EPIMENIA MARCELLA MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2528 RIDGE RUNNER RD
LAS VEGAS NM
87701-4971
US

IV. Provider business mailing address

2528 RIDGE RUNNER RD
LAS VEGAS NM
87701-4971
US

V. Phone/Fax

Practice location:
  • Phone: 505-425-2622
  • Fax: 505-425-9223
Mailing address:
  • Phone: 505-425-2622
  • Fax: 505-425-9223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2024-0480
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: