Healthcare Provider Details

I. General information

NPI: 1457422677
Provider Name (Legal Business Name): TERESA MIA MARTINEZ M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 OLD PECOS TRL STE G
SANTA FE NM
87505-4759
US

IV. Provider business mailing address

5714 QUAY DR NE
RIO RANCHO NM
87144-5157
US

V. Phone/Fax

Practice location:
  • Phone: 505-954-9940
  • Fax:
Mailing address:
  • Phone: 505-681-9942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4023
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: