Healthcare Provider Details

I. General information

NPI: 1144731761
Provider Name (Legal Business Name): JUAN CARLOS DEOSES BURCIAGA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 CAMINO ENTRADA
SANTA FE NM
87507-4851
US

IV. Provider business mailing address

2504 CAMINO ENTRADA
SANTA FE NM
87507-4851
US

V. Phone/Fax

Practice location:
  • Phone: 505-471-5006
  • Fax: 505-820-9220
Mailing address:
  • Phone: 505-471-5006
  • Fax: 505-820-9220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-10237
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number372693
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-11414
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: