Healthcare Provider Details

I. General information

NPI: 1801129184
Provider Name (Legal Business Name): NATHAN MATTHEW PADILLA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2009
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 W 2ND ST STE 116
ROSWELL NM
88201-2027
US

IV. Provider business mailing address

PO BOX 4425
ROSWELL NM
88202-4425
US

V. Phone/Fax

Practice location:
  • Phone: 575-840-1075
  • Fax: 575-623-1240
Mailing address:
  • Phone: 575-840-1075
  • Fax: 575-623-1240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-09926
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: