Provider Demographics
NPI:1407079627
Name:CERVANTES, PATRICIA V (MSW)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:V
Last Name:CERVANTES
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 IDALIA RD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-7526
Mailing Address - Country:US
Mailing Address - Phone:505-771-1466
Mailing Address - Fax:505-771-1454
Practice Address - Street 1:39 ACADEMY DR
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-8731
Practice Address - Country:US
Practice Address - Phone:505-898-0596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-062701041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4574869Medicaid