Healthcare Provider Details

I. General information

NPI: 1689127367
Provider Name (Legal Business Name): CLAUDIA ESCARENO-CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 EARLY ST
SANTA FE NM
87505-1607
US

IV. Provider business mailing address

102 N CORONADO AVE
ESPANOLA NM
87532-2700
US

V. Phone/Fax

Practice location:
  • Phone: 505-955-0410
  • Fax: 505-955-8577
Mailing address:
  • Phone: 505-629-1813
  • Fax: 505-753-4123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0182121
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: