Provider Demographics
NPI:1306197165
Name:SEDILLO, ALICIA J
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:J
Last Name:SEDILLO
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 1:3500 LONE TREE SW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031
Mailing Address - Country:US
Mailing Address - Phone:505-948-6224
Mailing Address - Fax:
Practice Address - Street 1:3500 LONE TREE ST SW
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-6288
Practice Address - Country:US
Practice Address - Phone:505-948-6224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-077971041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMX-07797OtherSTATE OF NEW MEXICO