Provider Demographics
NPI:1437658812
Name:VALDERAZ, EVGENIA
Entity Type:Individual
Prefix:
First Name:EVGENIA
Middle Name:
Last Name:VALDERAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 W AVENUE I
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-5017
Mailing Address - Country:US
Mailing Address - Phone:575-704-2514
Mailing Address - Fax:
Practice Address - Street 1:215 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-6065
Practice Address - Country:US
Practice Address - Phone:575-605-7074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-101811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical