Basic Information
Provider Information | |||||||||
NPI: | 1275612442 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARTIN-RODRIGUEZ | ||||||||
FirstName: | KELLEY | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LISW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RODRIGUEZ | ||||||||
OtherFirstName: | KELLEY | ||||||||
OtherMiddleName: | D | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LMSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 914 N CANAL ST | ||||||||
Address2: |   | ||||||||
City: | CARLSBAD | ||||||||
State: | NM | ||||||||
PostalCode: | 882205110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5758854836 | ||||||||
FaxNumber: | 5758879579 | ||||||||
Practice Location | |||||||||
Address1: | 914 N CANAL ST | ||||||||
Address2: |   | ||||||||
City: | CARLSBAD | ||||||||
State: | NM | ||||||||
PostalCode: | 882205110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5758854836 | ||||||||
FaxNumber: | 5758879579 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/06/2006 | ||||||||
LastUpdateDate: | 05/26/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | X-05589 | NM | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | I-06889 | NM | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 48857823 | 05 | NM |   | MEDICAID |