Provider Demographics
NPI:1245387893
Name:DWYER, KAREN D (LISW)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:D
Last Name:DWYER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:MS
Other - First Name:KAREN
Other - Middle Name:PENDLETTON
Other - Last Name:DWYER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW
Mailing Address - Street 1:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:NM
Mailing Address - Zip Code:87517-0095
Mailing Address - Country:US
Mailing Address - Phone:575-770-6396
Mailing Address - Fax:575-758-3598
Practice Address - Street 1:425 SO CARSON RD
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:NM
Practice Address - Zip Code:87517-0095
Practice Address - Country:US
Practice Address - Phone:575-770-6396
Practice Address - Fax:575-376-7177
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1-44301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM 100311Medicaid
NM338-327-201Medicare ID - Type Unspecified