Healthcare Provider Details

I. General information

NPI: 1083654537
Provider Name (Legal Business Name): SAMUEL NUNEZ LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 LIVINGSTON LOOP STE C1
SANTA TERESA NM
88008-9753
US

IV. Provider business mailing address

PO BOX 1063
SANTA TERESA NM
88008-1063
US

V. Phone/Fax

Practice location:
  • Phone: 575-824-9000
  • Fax: 866-596-6125
Mailing address:
  • Phone: 575-824-9000
  • Fax: 866-596-6125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI-07343
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number02067
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: