=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356089346
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHANA E MARTINEZ I
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2022
-----------------------------------------------------
Last Update Date | 05/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40014 OFFICE COURT DRIVE
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-395-9611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | JOHANAMARTINEZ@CENTERFORAUTISM.COM 4001OFFICE COURT DRIVE
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-395-9611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------