Healthcare Provider Details

I. General information

NPI: 1295687218
Provider Name (Legal Business Name): AMETHYST R DOUGLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2026
Last Update Date: 02/11/2026
Certification Date: 02/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 W AZTEC BLVD
AZTEC NM
87410-1818
US

IV. Provider business mailing address

1118 W AZTEC BLVD
AZTEC NM
87410-1818
US

V. Phone/Fax

Practice location:
  • Phone: 505-334-9474
  • Fax: 505-334-9861
Mailing address:
  • Phone: 505-334-9474
  • Fax: 505-334-9861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberSWB-2026-0065
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: