Healthcare Provider Details

I. General information

NPI: 1891177705
Provider Name (Legal Business Name): REGINA A MARES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2015
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 1ST ST
TULAROSA NM
88352-2702
US

IV. Provider business mailing address

504 1ST ST
TULAROSA NM
88352-2702
US

V. Phone/Fax

Practice location:
  • Phone: 575-585-8800
  • Fax:
Mailing address:
  • Phone: 575-585-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2024-0855
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: