MEDICARE: MS. VANESSA TAVAREZ-CORRAL LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	M-06539	NM

General Provider Information

NPI Number	:	1205256179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VANESSA TAVAREZ-CORRAL LMSW

Provider Business Mailing Address
First Line	:	1016 GILMER WAY
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-1505
Country	:	US
Telephone Number	:	575-528-5127
Fax Number	:

Provider Business Practice Location Address
First Line	:	1170 N SOLANO DR STE K
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-2371
Country	:	US
Telephone Number	:	575-528-5127
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2014
Last Update Date	:	04/18/2014

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