=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114719325
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ESTIN MICHAEL TALAVERA LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2025
-----------------------------------------------------
Last Update Date | 05/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 530 N CHURCH ST
-----------------------------------------------------
City | LAS CRUCES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88001-3440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-526-9878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2110 SAN PATRICIO LOOP
-----------------------------------------------------
City | LAS CRUCES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88011-4202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-899-7833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | SWB-2025-0327
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------