Provider Demographics
NPI:1437464138
Name:RALEY, PAULA L (LCSW)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:L
Last Name:RALEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2441 CABEZON BLVD SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124
Mailing Address - Country:US
Mailing Address - Phone:505-717-1155
Mailing Address - Fax:505-717-1473
Practice Address - Street 1:2112 MAIN STREET NE
Practice Address - Street 2:SUITE A
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031
Practice Address - Country:US
Practice Address - Phone:505-916-5900
Practice Address - Fax:505-916-5901
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM07384104100000X
NM1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM49335871Medicaid