Healthcare Provider Details

I. General information

NPI: 1710310016
Provider Name (Legal Business Name): TONY BOBADILLA LCSW, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S MAIN ST STE 249
LAS CRUCES NM
88001-1206
US

IV. Provider business mailing address

505 S MAIN ST STE 249
LAS CRUCES NM
88001-1206
US

V. Phone/Fax

Practice location:
  • Phone: 575-527-5884
  • Fax: 575-527-5886
Mailing address:
  • Phone: 575-527-5884
  • Fax: 575-527-5886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-08350
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-09780
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: