Provider Demographics
NPI:1861240608
Name:FENNER, MARTIN ALAN (CCSS)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:ALAN
Last Name:FENNER
Suffix:
Gender:M
Credentials:CCSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-4254
Mailing Address - Country:US
Mailing Address - Phone:575-835-8991
Mailing Address - Fax:
Practice Address - Street 1:801 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-4254
Practice Address - Country:US
Practice Address - Phone:575-835-8991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator