Provider Demographics
NPI:1194396945
Name:MESTAS, DESIRAE KALIE
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:KALIE
Last Name:MESTAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 GIBSON BLVD SE APT 2058
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-3366
Mailing Address - Country:US
Mailing Address - Phone:505-692-3719
Mailing Address - Fax:
Practice Address - Street 1:1801 GIBSON BLVD SE APT 2058
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-3366
Practice Address - Country:US
Practice Address - Phone:505-692-3719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician