Basic Information
| Provider Information | |||||||||
| NPI: | 1669696811 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. MARTIN'S HOSPITALITY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 OSO PL | ||||||||
| Address2: | |||||||||
| City: | JEMEZ SPRINGS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870259043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052495046 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 3RD ST NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871021403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057648231 | ||||||||
| FaxNumber: | 5052481351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PALMA | ||||||||
| AuthorizedOfficialFirstName: | ANNE | ||||||||
| AuthorizedOfficialMiddleName: | SHARON | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOTHERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 5052495046 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MA,MS, LPCC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0814 | NM | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0814 | 01 | NM | PSYCHOTHERAPY LICENSE | OTHER |