Provider Demographics
NPI:1336703156
Name:VARGAS, EDWIN (LMSW)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:VARGAS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 GRANDE BLVD SE STE B
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1695
Mailing Address - Country:US
Mailing Address - Phone:505-218-6383
Mailing Address - Fax:505-636-6338
Practice Address - Street 1:4200 MEADOWLARK LN SE STE 4A
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1050
Practice Address - Country:US
Practice Address - Phone:505-218-6383
Practice Address - Fax:505-636-6338
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-090731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM05879337Medicaid