Basic Information
| Provider Information | |||||||||
| NPI: | 1457592255 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | MARTINE | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2549 TWIN BUTTES DR NE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871446742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057962095 | ||||||||
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| Practice Location | |||||||||
| Address1: | 184 UNSER BLVD NE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871244045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058960928 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2009 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
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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 | 101YM0800X | 0129871 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.