Provider Demographics
NPI:1548432065
Name:CASA DE CORAZON
Entity Type:Organization
Organization Name:CASA DE CORAZON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LINCENSED MASTERS OF SOCIAL WORK
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:MARGARETE
Authorized Official - Last Name:WENZKE
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:505-944-5560
Mailing Address - Street 1:PO BOX 3157
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87533-3157
Mailing Address - Country:US
Mailing Address - Phone:505-747-1991
Mailing Address - Fax:505-753-6462
Practice Address - Street 1:314 DON FERNANDO ST
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5953
Practice Address - Country:US
Practice Address - Phone:505-747-1991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-06643251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health