Healthcare Provider Details

I. General information

NPI: 1396215216
Provider Name (Legal Business Name): CHAYA ROSE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5203 JUAN TABO BLVD NE STE 2A
ALBUQUERQUE NM
87111-2691
US

IV. Provider business mailing address

5203 JUAN TABO BLVD NE STE 2A
ALBUQUERQUE NM
87111-2691
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-6121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-10227
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: