Healthcare Provider Details

I. General information

NPI: 1245505205
Provider Name (Legal Business Name): CHAVONNE MCCLAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHAVONNE LONG

II. Dates (important events)

Enumeration Date: 03/09/2012
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7520 MONTGOMERY BLVD NE BLDG E15
ALBUQUERQUE NM
87109-1586
US

IV. Provider business mailing address

7520 MONTGOMERY BLVD NE BLDG E15
ALBUQUERQUE NM
87109-1586
US

V. Phone/Fax

Practice location:
  • Phone: 505-226-6380
  • Fax: 505-214-5852
Mailing address:
  • Phone: 505-226-6380
  • Fax: 505-214-5852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW017810
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-09259
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: