Healthcare Provider Details

I. General information

NPI: 1619415254
Provider Name (Legal Business Name): MARY MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY BLACKWELL BCBA

II. Dates (important events)

Enumeration Date: 02/02/2017
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 HILLRISE CIR
LAS CRUCES NM
88011-4741
US

IV. Provider business mailing address

4620 OLIVER MANOR DR
PARRISH FL
34219-7575
US

V. Phone/Fax

Practice location:
  • Phone: 720-966-8200
  • Fax:
Mailing address:
  • Phone: 484-408-4272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: