Healthcare Provider Details

I. General information

NPI: 1225676554
Provider Name (Legal Business Name): DELARAM HEIDARI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CHAMISA VLG UNIT 268
LAS CRUCES NM
88001-6927
US

IV. Provider business mailing address

300 CHAMISA VLG UNIT 268
LAS CRUCES NM
88001-6927
US

V. Phone/Fax

Practice location:
  • Phone: 575-652-0693
  • Fax:
Mailing address:
  • Phone: 575-652-0693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: