Provider Demographics
NPI:1467600593
Name:KINLICHEENIE, DARVA VICKI (LMSW)
Entity Type:Individual
Prefix:
First Name:DARVA
Middle Name:VICKI
Last Name:KINLICHEENIE
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 1319
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-1319
Mailing Address - Country:US
Mailing Address - Phone:505-368-5163
Mailing Address - Fax:505-368-5502
Practice Address - Street 1:2011 TROY KING ROAD
Practice Address - Street 2:#444
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-1319
Practice Address - Country:US
Practice Address - Phone:505-368-5163
Practice Address - Fax:505-368-5502
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-062031041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMJ7695Medicaid