Healthcare Provider Details

I. General information

NPI: 1902440191
Provider Name (Legal Business Name): LORI ANNE VALLEJOS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 RIO SAN JOSE
LAGUNA NM
87026
US

IV. Provider business mailing address

7 RIO SAN JOSE
LAGUNA NM
87026
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5730
  • Fax:
Mailing address:
  • Phone: 505-552-5730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-11015
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: