=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780719658
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL HEREDIA-SANCHEZ LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 11/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 LIVINGSTON LOOP STE C1
-----------------------------------------------------
City | SANTA TERESA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88008-9753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-824-9000
-----------------------------------------------------
Fax | 866-232-9241
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 W GRIGGS AVE
-----------------------------------------------------
City | LAS CRUCES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88001-1234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-647-2800
-----------------------------------------------------
Fax | 575-647-2898
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C-06430
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------