Provider Demographics
NPI:1598304990
Name:NEZ, CHASITITY BEULAH
Entity Type:Individual
Prefix:
First Name:CHASITITY
Middle Name:BEULAH
Last Name:NEZ
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:PO BOX 1793
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND
Mailing Address - State:NM
Mailing Address - Zip Code:87417-1793
Mailing Address - Country:US
Mailing Address - Phone:505-793-2336
Mailing Address - Fax:
Practice Address - Street 1:37 RD 7101 #127
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-793-2336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician