Healthcare Provider Details

I. General information

NPI: 1952439457
Provider Name (Legal Business Name): JODY DAPHNE ANTAL-NICKS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3949 CORRALES RD STE 205
CORRALES NM
87048-9348
US

IV. Provider business mailing address

3949 CORRALES RD STE 205
CORRALES NM
87048-9348
US

V. Phone/Fax

Practice location:
  • Phone: 505-385-0439
  • Fax:
Mailing address:
  • Phone: 505-385-0439
  • Fax: 505-212-0435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberC-04805
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberC-04805
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: