Healthcare Provider Details

I. General information

NPI: 1861919854
Provider Name (Legal Business Name): CHINYELU CHIMEZIE OBI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 10/13/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 S. MIRANDA ST.
LAS CRUCES NM
88005
US

IV. Provider business mailing address

385 CALLE DE ALEGRA STE A
LAS CRUCES NM
88005-3423
US

V. Phone/Fax

Practice location:
  • Phone: 575-647-2800
  • Fax: 575-647-2898
Mailing address:
  • Phone: 575-526-1105
  • Fax: 575-524-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-10055
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-11902
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: