Provider Demographics
NPI:1437420791
Name:CHAVEZ, CARLA DIANA
Entity Type:Individual
Prefix:MS
First Name:CARLA
Middle Name:DIANA
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CARLA
Other - Middle Name:DIANA
Other - Last Name:CHAVEZ-TRUJILLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:505 NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4319
Mailing Address - Country:US
Mailing Address - Phone:505-690-1171
Mailing Address - Fax:
Practice Address - Street 1:706 KANE DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4949
Practice Address - Country:US
Practice Address - Phone:505-690-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
NM0096141101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM33786569Medicaid