Provider Demographics
NPI:1043869647
Name:BURCIAGA, ROSAISELA M
Entity Type:Individual
Prefix:
First Name:ROSAISELA
Middle Name:M
Last Name:BURCIAGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6949 GOLDEN MESA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-3458
Mailing Address - Country:US
Mailing Address - Phone:505-577-7343
Mailing Address - Fax:
Practice Address - Street 1:4157 WALKING RAIN RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-0825
Practice Address - Country:US
Practice Address - Phone:505-982-5225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3922551041S0200X
NMM-04648104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty