=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568936433
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA M PACHECO LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2019
-----------------------------------------------------
Last Update Date | 01/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 AVENIDA DE LAS CAMPANAS
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87507-5369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-467-1808
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 68 COYOTE TRL
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87508-8631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-629-6334
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041S0200X
-----------------------------------------------------
Taxonomy Name | School Social Worker
-----------------------------------------------------
License Number | M09231
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------