Healthcare Provider Details

I. General information

NPI: 1659944080
Provider Name (Legal Business Name): STEPHEN JEROME CHAVEZ LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HWY 60
SOCORRO NM
87801-3914
US

IV. Provider business mailing address

1200 HIGHWAY 60
SOCORRO NM
87801-3914
US

V. Phone/Fax

Practice location:
  • Phone: 575-835-2444
  • Fax:
Mailing address:
  • Phone: 575-835-2444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberX-11998
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: