MEDICARE: KENNETH YARA LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041S0200X	School Social Worker	105992513	NM

General Provider Information

NPI Number	:	1083159578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH YARA LMSW

Provider Business Mailing Address
First Line	:	2422 CALLE ALEGRE
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701
Country	:	US
Telephone Number	:	505-459-2062
Fax Number	:

Provider Business Practice Location Address
First Line	:	2422 CALLE ALEGRE
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4802
Country	:	US
Telephone Number	:	505-459-2062
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2016
Last Update Date	:	12/20/2016

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