=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700060506
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | P ROBERT LEE MARTINEZ LPCMHC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2007
-----------------------------------------------------
Last Update Date | 12/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 05A CERRO DE PALOMAS
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87506-0084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-983-3029
-----------------------------------------------------
Fax | 505-983-3029
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 578
-----------------------------------------------------
City | TESUQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87574-0578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-983-3029
-----------------------------------------------------
Fax | 505-983-3029
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0033
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------