Healthcare Provider Details

I. General information

NPI: 1922210764
Provider Name (Legal Business Name): HOMER AVALOS AVALOS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 GERONIMO
CHAPPARAL NM
88081
US

IV. Provider business mailing address

300-2 MCCOMBS RD # 16
CHAPARRAL NM
88081-7937
US

V. Phone/Fax

Practice location:
  • Phone: 915-691-5555
  • Fax:
Mailing address:
  • Phone: 915-691-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1780
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: