Provider Demographics
NPI:1477026706
Name:COLLETTE, LEAH (CSW)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:COLLETTE
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 OJO COURT
Mailing Address - Street 2:
Mailing Address - City:FARMINGTGON
Mailing Address - State:NM
Mailing Address - Zip Code:87401
Mailing Address - Country:US
Mailing Address - Phone:505-564-4804
Mailing Address - Fax:
Practice Address - Street 1:1615 OJO COURT
Practice Address - Street 2:
Practice Address - City:FARMINGTGON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-564-4804
Practice Address - Fax:505-564-4857
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1477026706Medicaid