1336880640 NPI number — YADALIS Z MARTINEZ LMSW

Table of content: YADALIS Z MARTINEZ LMSW (NPI 1336880640)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336880640 NPI number — YADALIS Z MARTINEZ LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTINEZ
Provider First Name:
YADALIS
Provider Middle Name:
Z
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336880640
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1311 N GRANT ST STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILVER CITY
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88061-5134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-388-1447
Provider Business Mailing Address Fax Number:
575-388-1447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
603 HADECO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LORDSBURG
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88045-1813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-542-8447
Provider Business Practice Location Address Fax Number:
575-542-8447
Provider Enumeration Date:
04/02/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  X-12352 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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