Provider Demographics
NPI:1104184266
Name:SAMFORD, DEZAREE TAMARA LEE (INTER)
Entity Type:Individual
Prefix:MISS
First Name:DEZAREE
Middle Name:TAMARA LEE
Last Name:SAMFORD
Suffix:
Gender:F
Credentials:INTER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 YALE AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-4536
Mailing Address - Country:US
Mailing Address - Phone:575-740-6873
Mailing Address - Fax:
Practice Address - Street 1:2413 YALE AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-4536
Practice Address - Country:US
Practice Address - Phone:575-740-6873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18677037Medicaid