Provider Demographics
NPI:1043984966
Name:CONCHA, ANAMARIE ALEXANDRIA (CPSW)
Entity Type:Individual
Prefix:
First Name:ANAMARIE
Middle Name:ALEXANDRIA
Last Name:CONCHA
Suffix:
Gender:F
Credentials:CPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1846
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-1846
Mailing Address - Country:US
Mailing Address - Phone:575-758-2694
Mailing Address - Fax:575-758-5104
Practice Address - Street 1:501 PASEO DEL PUEBLO NORTE
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-1846
Practice Address - Country:US
Practice Address - Phone:575-758-2694
Practice Address - Fax:575-758-5104
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1047101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM72150041Medicaid