Provider Demographics
NPI:1619736642
Name:SMITH, SANDRA IVETH
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:IVETH
Last Name:SMITH
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 1:3401 CANDELARIA RD NE STE B
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-1946
Mailing Address - Country:US
Mailing Address - Phone:505-804-0855
Mailing Address - Fax:
Practice Address - Street 1:3401 CANDELARIA RD NE STE D
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1946
Practice Address - Country:US
Practice Address - Phone:505-804-0855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2024-0007104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker