Healthcare Provider Details

I. General information

NPI: 1679118491
Provider Name (Legal Business Name): CHRISTINA CHAVEZ LCSW, CCM, IMH-E
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2019
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3736 EUBANK BLVD NE STE B1
ALBUQUERQUE NM
87111-3583
US

IV. Provider business mailing address

2809 19TH ST NW
ALBUQUERQUE NM
87104-2405
US

V. Phone/Fax

Practice location:
  • Phone: 505-340-6743
  • Fax:
Mailing address:
  • Phone: 505-340-6743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-12109
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM10363
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: