Healthcare Provider Details

I. General information

NPI: 1043240195
Provider Name (Legal Business Name): THERESA LYNN RHODES LMSW, LISW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 01/04/2020
Certification Date: 01/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 CAMINO SIN PASADA
CORRALES NM
87048-8539
US

IV. Provider business mailing address

PO BOX 2239
CORRALES NM
87048-2239
US

V. Phone/Fax

Practice location:
  • Phone: 505-553-2969
  • Fax: 505-890-8480
Mailing address:
  • Phone: 505-553-2969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-05875
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: