Provider Demographics
NPI:1265066104
Name:MARTINEZ QUINTANA, CHEYANNE ROSE
Entity type:Individual
Prefix:MISS
First Name:CHEYANNE
Middle Name:ROSE
Last Name:MARTINEZ QUINTANA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:968 OLD LAS VEGAS HWY
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-1407
Mailing Address - Country:US
Mailing Address - Phone:505-901-1554
Mailing Address - Fax:
Practice Address - Street 1:968 OLD LAS VEGAS HWY
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1407
Practice Address - Country:US
Practice Address - Phone:505-901-1554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-01
Last Update Date:2020-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM515184040106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician