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NPI Code Detail

MEDICARE: DEIDRA MARIE CORDOVA LMSW

MEDICARE: DEIDRA MARIE CORDOVA 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
1104100000XSocial WorkerM-09998NM
21041C0700XClinical Social WorkerC-10903NM

General Provider Information

NPI Number : 1851806525
Entity Type Code : Individual
Provider Name (Legal Business Name) : DEIDRA MARIE CORDOVA LMSW
Provider Business Mailing Address
First Line : 624 UNIVERSITY AVE
Second Line :
City : LAS VEGAS
State : NM
Zip : 87701-4278
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2534 RIDGE RUNNER RD
Second Line :
City : LAS VEGAS
State : NM
Zip : 87701-4971
Country : US
Telephone Number : 505-617-1180
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/04/2017
Last Update Date : 05/07/2021

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