Provider Demographics
NPI:1437134046
Name:DEVORE, DEANNA (LMSW)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:DEVORE
Suffix:
Gender:F
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:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:505-368-8100
Mailing Address - Fax:505-368-8028
Practice Address - Street 1:6 ROAD 7586
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-4934
Practice Address - Country:US
Practice Address - Phone:505-368-8100
Practice Address - Fax:505-368-8028
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZM4096104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39506878Medicaid