Healthcare Provider Details

I. General information

NPI: 1063167187
Provider Name (Legal Business Name): STEPHEN J CHAVEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 PEDRO CHAVEZ LN NE
LOS LUNAS NM
87031-6522
US

IV. Provider business mailing address

560 PEDRO CHAVEZ LN NE
LOS LUNAS NM
87031-6522
US

V. Phone/Fax

Practice location:
  • Phone: 505-363-7091
  • Fax:
Mailing address:
  • Phone: 505-363-7091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN JEROME CHAVEZ
Title or Position: CLINICIAN
Credential: LMSW
Phone: 505-363-7091