Healthcare Provider Details

I. General information

NPI: 1548603392
Provider Name (Legal Business Name): WILLIAM M MARTIN M.A.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 7TH ST STE A
LAS VEGAS NM
87701-4966
US

IV. Provider business mailing address

2301 7TH ST STE A
LAS VEGAS NM
87701-4966
US

V. Phone/Fax

Practice location:
  • Phone: 505-454-9611
  • Fax: 505-454-8079
Mailing address:
  • Phone: 505-454-9611
  • Fax: 505-454-8079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0157821
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: