Healthcare Provider Details

I. General information

NPI: 1104150242
Provider Name (Legal Business Name): ROSELLA G. MARTINEZ SAA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2009
Last Update Date: 09/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 SIPAPU ST BOX 6952
TAOS NM
87571-6489
US

IV. Provider business mailing address

GALLINA CANYON ROAD HOUSE #12
VALDEZ NM
87580
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-5758
  • Fax: 575-758-2832
Mailing address:
  • Phone: 575-776-8009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0111351
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: