Provider Demographics
NPI:1376171033
Name:CARPENTER, KATERI MARIE (CSW)
Entity Type:Individual
Prefix:
First Name:KATERI
Middle Name:MARIE
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 SUDDERTH DRIVE
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-6103
Mailing Address - Country:US
Mailing Address - Phone:575-630-0571
Mailing Address - Fax:575-630-0574
Practice Address - Street 1:1400 SUDDERTH DRIVE
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6103
Practice Address - Country:US
Practice Address - Phone:575-630-0571
Practice Address - Fax:575-630-0574
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM052741572Medicaid