Provider Demographics
NPI:1760512784
Name:MARTINEZ, AMANDA SUSANNE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUSANNE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 SAN PATRICIO LOOP
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4203
Mailing Address - Country:US
Mailing Address - Phone:505-202-2714
Mailing Address - Fax:
Practice Address - Street 1:2020 SAN PATRICIO LOOP
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4203
Practice Address - Country:US
Practice Address - Phone:505-202-2714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3736235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist