Basic Information
| Provider Information | |||||||||
| NPI: | 1346762192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VALDEZ | ||||||||
| FirstName: | CRISTAL | ||||||||
| MiddleName: | MARTINEZ | ||||||||
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| Credential: | MS, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1106 | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875671106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059271045 | ||||||||
| FaxNumber: | 5057531219 | ||||||||
| Practice Location | |||||||||
| Address1: | 708 LA JOYA STREET | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875322877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057536550 | ||||||||
| FaxNumber: | 5057531219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2017 | ||||||||
| LastUpdateDate: | 07/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 3628 | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 3628 | 01 | NM | PROFESSIONAL LICENSE NUMBER | OTHER |