Provider Demographics
NPI:1144768417
Name:HERNANDEZ, LEASETTE MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:LEASETTE
Middle Name:MARIE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:LEASETTE
Other - Middle Name:MARIE
Other - Last Name:CONWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:385 CALLE DE ALEGRA STE A
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3423
Mailing Address - Country:US
Mailing Address - Phone:575-526-1105
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:510 E LISA DR
Practice Address - Street 2:
Practice Address - City:CHAPARRAL
Practice Address - State:NM
Practice Address - Zip Code:88081
Practice Address - Country:US
Practice Address - Phone:575-824-0820
Practice Address - Fax:575-824-1021
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-117331041C0700X
NMX-10715104100000X
NMM-10562104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM91656556Medicaid