=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407904972
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONALD A. CHAVEZ LISW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 02/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6 JARAMILLO RD
-----------------------------------------------------
City | BELEN
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87002-7357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-864-3281
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1351
-----------------------------------------------------
City | BELEN
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87002-1351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-864-3281
-----------------------------------------------------
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 | I-0453
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------