Healthcare Provider Details

I. General information

NPI: 1316661713
Provider Name (Legal Business Name): DARIQUETTA DORRY CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 COLLEGE DR
GALLUP NM
87301-5600
US

IV. Provider business mailing address

312 BLACK DIAMOND CANYON DR
GALLUP NM
87301-5356
US

V. Phone/Fax

Practice location:
  • Phone: 505-397-5172
  • Fax:
Mailing address:
  • Phone: 505-906-1715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberSWB-2026-0636
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2023-0793
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: