Provider Demographics
NPI:1316382229
Name:NEVARES, NICK
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:
Last Name:NEVARES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3377 PARK RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-1106
Mailing Address - Country:US
Mailing Address - Phone:575-524-0732
Mailing Address - Fax:
Practice Address - Street 1:3377 PARK RIDGE PL
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-1106
Practice Address - Country:US
Practice Address - Phone:575-524-0732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-06
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-4493104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMM-4493OtherLICENSE SOCIAL WORKER