Healthcare Provider Details

I. General information

NPI: 1780117267
Provider Name (Legal Business Name): JOHNNA YEAGER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 W MCKAY ST
CARLSBAD NM
88220-5067
US

IV. Provider business mailing address

1016 ALBERT ST
CARLSBAD NM
88220-4528
US

V. Phone/Fax

Practice location:
  • Phone: 575-302-7035
  • Fax:
Mailing address:
  • Phone: 575-636-2468
  • Fax: 575-218-7534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-11219
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: