Healthcare Provider Details

I. General information

NPI: 1700060506
Provider Name (Legal Business Name): P ROBERT LEE MARTINEZ LPCMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: P ROBERT LEE MARTINEZ LPCMHC

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 12/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

05A CERRO DE PALOMAS
SANTA FE NM
87506-0084
US

IV. Provider business mailing address

PO BOX 578
TESUQUE NM
87574-0578
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-3029
  • Fax: 505-983-3029
Mailing address:
  • Phone: 505-983-3029
  • Fax: 505-983-3029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0033
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: