Healthcare Provider Details

I. General information

NPI: 1093873135
Provider Name (Legal Business Name): DIANE C. CHAVEZ MA, LPCC, LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 JUAN TABO BLVD NE STE 112
ALBUQUERQUE NM
87111-2684
US

IV. Provider business mailing address

801 GUAYMAS PL NE
ALBUQUERQUE NM
87108-2331
US

V. Phone/Fax

Practice location:
  • Phone: 505-503-6800
  • Fax:
Mailing address:
  • Phone: 505-238-7468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0082381
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: