Healthcare Provider Details

I. General information

NPI: 1609796408
Provider Name (Legal Business Name): DLW FORENSIC COMMUNITY NAVIGATION SPECIALIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3803 ASPEN AVE NE APT 25
ALBUQUERQUE NM
87110-5651
US

IV. Provider business mailing address

3803 ASPEN AVE NE APT 25
ALBUQUERQUE NM
87110-5651
US

V. Phone/Fax

Practice location:
  • Phone: 505-238-4257
  • Fax: 505-238-4257
Mailing address:
  • Phone: 505-238-4257
  • Fax: 505-238-4257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DEMETRE WALLACE
Title or Position: OWNER
Credential: CCHW,CCSS
Phone: 505-238-4257