Healthcare Provider Details

I. General information

NPI: 1124211404
Provider Name (Legal Business Name): STATE OF NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3695 HOT SPRINGS BLVD
LAS VEGAS NM
87701-9549
US

IV. Provider business mailing address

3695 HOT SPRINGS BLVD
LAS VEGAS NM
87701-9549
US

V. Phone/Fax

Practice location:
  • Phone: 505-454-2100
  • Fax:
Mailing address:
  • Phone: 505-454-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number
License Number State

VIII. Authorized Official

Name: STEVE MARTINEZ
Title or Position: INTERIM ADMINISTRATOR
Credential:
Phone: 505-454-2203