Healthcare Provider Details

I. General information

NPI: 1538660428
Provider Name (Legal Business Name): SARAH REBECCA BALES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 05/07/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 1/2 S 3RD ST
RATON NM
87740
US

IV. Provider business mailing address

PO BOX 1343
RATON NM
87740-1343
US

V. Phone/Fax

Practice location:
  • Phone: 575-303-2260
  • Fax: 575-303-4624
Mailing address:
  • Phone: 323-480-3710
  • Fax: 575-221-5561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-17913
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-96025
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10834
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: