Healthcare Provider Details

I. General information

NPI: 1164697280
Provider Name (Legal Business Name): ELIZABETH URBAN CANDELARIA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 SUDDERTH DR.
RUIDOSO NM
88345
US

IV. Provider business mailing address

100 W GRIGGS AVE
LAS CRUCES NM
88001-1234
US

V. Phone/Fax

Practice location:
  • Phone: 575-630-0571
  • Fax: 575-630-0574
Mailing address:
  • Phone: 575-647-2800
  • Fax: 575-647-2898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-04551
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: