Provider Demographics
NPI:1609100221
Name:CHAVEZ, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CHAVEZ
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 1:1302 CALLE DE LA MERCED STE H
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2630
Mailing Address - Country:US
Mailing Address - Phone:505-747-0081
Mailing Address - Fax:505-747-0083
Practice Address - Street 1:1302 CALLE DE LA MERCED STE H
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2630
Practice Address - Country:US
Practice Address - Phone:505-747-0081
Practice Address - Fax:505-747-0083
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME7436Medicaid