Provider Demographics
NPI:1407909997
Name:CANDELARIA ARCHULETA, LETICIA (SW)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:CANDELARIA ARCHULETA
Suffix:
Gender:F
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 COMANCHE RD NE
Mailing Address - Street 2:MCKINLEY MS
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1176
Mailing Address - Country:US
Mailing Address - Phone:505-881-9390
Mailing Address - Fax:
Practice Address - Street 1:4500 COMANCHE RD NE
Practice Address - Street 2:MCKINLEY MS
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1176
Practice Address - Country:US
Practice Address - Phone:505-881-9390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM055601041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM89502051Medicaid