Provider Demographics
NPI:1629107149
Name:OAXACA, LAURA VERONICA JR (M A)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:VERONICA
Last Name:OAXACA
Suffix:JR
Gender:F
Credentials:M A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 NORTH LOOP
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-7204
Mailing Address - Country:US
Mailing Address - Phone:505-939-9066
Mailing Address - Fax:505-537-3921
Practice Address - Street 1:900 CENTRAL
Practice Address - Street 2:
Practice Address - City:BAYARD
Practice Address - State:NM
Practice Address - Zip Code:88023
Practice Address - Country:US
Practice Address - Phone:505-537-4000
Practice Address - Fax:505-537-3921
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM285262103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM36950017Medicaid