Provider Demographics
NPI:1114569605
Name:AVILA MIRAMONTES, VICENTE (LBSW)
Entity Type:Individual
Prefix:
First Name:VICENTE
Middle Name:
Last Name:AVILA MIRAMONTES
Suffix:
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13A SAN MARCOS LOOP
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-7083
Mailing Address - Country:US
Mailing Address - Phone:505-986-4007
Mailing Address - Fax:
Practice Address - Street 1:13A SAN MARCOS LOOP
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-7083
Practice Address - Country:US
Practice Address - Phone:505-986-4007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3928851041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty