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General NPI Number Information
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NPI Number | 1306558184
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Entity Type | Individual
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Provider Name | CEDRA D ETESAM LSW
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Gender | Female
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Dates
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Enumeration Date | 12/23/2022
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Last Update Date | 04/22/2025
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Provider Practice Location Address
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Address Line | 15682 STATE HIGHWAY 172 LOT 34
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City | IGNACIO
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State | CO
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Zip | 81137-9742
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Country | US
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Telephone | 970-426-9591
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Fax |
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Provider Business Mailing Address
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Address Line | 15682 STATE HIGHWAY 172 LOT 34
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City | IGNACIO
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State | CO
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Zip | 81137-9742
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Country | US
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Telephone | 970-426-9591
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0009925857
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License Number State | CO
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