Healthcare Provider Details

I. General information

NPI: 1316100274
Provider Name (Legal Business Name): MARTIN THOMAS KLEHN LISW/LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 5TH ST SUITE 101
SANTA FE NM
87505-5403
US

IV. Provider business mailing address

PO BOX 2635
SANTA FE NM
87504-2635
US

V. Phone/Fax

Practice location:
  • Phone: 505-438-1853
  • Fax: 505-438-2475
Mailing address:
  • Phone: 505-438-1853
  • Fax: 505-438-2475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-04823
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: