Healthcare Provider Details

I. General information

NPI: 1881479467
Provider Name (Legal Business Name): MICHELLE MARTIN CPSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2023
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 SOUTHERN BLVD SE STE 105
RIO RANCHO NM
87124-5859
US

IV. Provider business mailing address

3301 SOUTHERN BLVD SE STE 105
RIO RANCHO NM
87124-5859
US

V. Phone/Fax

Practice location:
  • Phone: 505-270-0840
  • Fax: 505-581-3131
Mailing address:
  • Phone: 505-270-0840
  • Fax: 505-581-3131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1586
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: