Healthcare Provider Details

I. General information

NPI: 1518030451
Provider Name (Legal Business Name): SHELLEY DARLENE MARTINEZ MA, LPCC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 11/28/2023
Certification Date: 11/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 GRANDE BLVD SE STE C
RIO RANCHO NM
87124-1654
US

IV. Provider business mailing address

2320 GRANDE BLVD SE STE C
RIO RANCHO NM
87124-1654
US

V. Phone/Fax

Practice location:
  • Phone: 505-410-1773
  • Fax:
Mailing address:
  • Phone: 505-410-1773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH005695
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: