Provider Demographics
NPI:1245606649
Name:DONDANVILLE, AMY JO (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:DONDANVILLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 537
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-0537
Mailing Address - Country:US
Mailing Address - Phone:575-224-2710
Mailing Address - Fax:
Practice Address - Street 1:16 CAMINO DE LOS VECINOS
Practice Address - Street 2:
Practice Address - City:RANCHOS DE TAOS
Practice Address - State:NM
Practice Address - Zip Code:87557
Practice Address - Country:US
Practice Address - Phone:575-224-2710
Practice Address - Fax:575-708-2559
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-091781041C0700X
NMC-104001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1245606649OtherTYPE 1 NPI