Healthcare Provider Details

I. General information

NPI: 1356089346
Provider Name (Legal Business Name): JOHANA E MARTINEZ I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2022
Last Update Date: 05/20/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40014 OFFICE COURT DRIVE
SANTA FE NM
87507
US

IV. Provider business mailing address

JOHANAMARTINEZ@CENTERFORAUTISM.COM 4001OFFICE COURT DRIVE
SANTA FE NM
87507
US

V. Phone/Fax

Practice location:
  • Phone: 505-395-9611
  • Fax:
Mailing address:
  • Phone: 505-395-9611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: