Healthcare Provider Details

I. General information

NPI: 1255628061
Provider Name (Legal Business Name): TANYA TIJERINA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 08/06/2023
Certification Date: 08/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10500 COYOTE CANYON PL NW
ALBUQUERQUE NM
87114-5948
US

IV. Provider business mailing address

10500 COYOTE CANYON PL NW
ALBUQUERQUE NM
87114-5948
US

V. Phone/Fax

Practice location:
  • Phone: 505-203-5328
  • Fax:
Mailing address:
  • Phone: 505-203-5328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberC-08274
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: