Healthcare Provider Details

I. General information

NPI: 1659782480
Provider Name (Legal Business Name): YANET MONTELONGO LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E MESCALERO RD
ROSWELL NM
88201
US

IV. Provider business mailing address

110 E MESCALERO RD
ROSWELL NM
88201-6542
US

V. Phone/Fax

Practice location:
  • Phone: 575-755-2272
  • Fax: 575-622-3325
Mailing address:
  • Phone: 575-755-1486
  • Fax: 575-622-3325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-10232
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberB-08295
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: