Provider Demographics
NPI:1083196497
Name:FERRALEZ, THERESA MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MICHELLE
Last Name:FERRALEZ
Suffix:
Gender:F
Credentials:LCSW
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 33
Mailing Address - Street 2:
Mailing Address - City:ORGAN
Mailing Address - State:NM
Mailing Address - Zip Code:88052-0033
Mailing Address - Country:US
Mailing Address - Phone:575-649-8355
Mailing Address - Fax:
Practice Address - Street 1:1909 CUBA AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5646
Practice Address - Country:US
Practice Address - Phone:575-649-8355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-31
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
M-09635104100000X
NMM-09635104100000X
1041C0700X
NMC-105591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker