Healthcare Provider Details

I. General information

NPI: 1699663526
Provider Name (Legal Business Name): JAVIER CORNEJO JR. CPSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2025
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 N TELSHOR BLVD STE C
LAS CRUCES NM
88011-8243
US

IV. Provider business mailing address

816 LIVESAY STREET POBOX 1482
ANTHONY NM
88021
US

V. Phone/Fax

Practice location:
  • Phone: 575-215-3389
  • Fax:
Mailing address:
  • Phone: 915-352-8932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2026-0720
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1565
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: