Healthcare Provider Details

I. General information

NPI: 1508178138
Provider Name (Legal Business Name): PAUL THOMAS CHAVEZ M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2010
Last Update Date: 07/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 VIRGINIA ST NE STE 400
ALBUQUERQUE NM
87110-4659
US

IV. Provider business mailing address

PO BOX 7146
ALBUQUERQUE NM
87194-7146
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-6314
  • Fax: 505-275-0296
Mailing address:
  • Phone: 505-688-1228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0132911
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: