Healthcare Provider Details

I. General information

NPI: 1740973833
Provider Name (Legal Business Name): KENIA I ALVIDREZ LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2023
Last Update Date: 07/24/2023
Certification Date: 07/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 OLD PECOS TRL STE A
SANTA FE NM
87505-4778
US

IV. Provider business mailing address

1660 OLD PECOS TRL STE A
SANTA FE NM
87505-4778
US

V. Phone/Fax

Practice location:
  • Phone: 505-657-9708
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2023-0456
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: