Provider Demographics
NPI:1629675632
Name:ANALLA, CHARLENE
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:ANALLA
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 27258
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-7258
Mailing Address - Country:US
Mailing Address - Phone:505-242-4399
Mailing Address - Fax:505-944-7840
Practice Address - Street 1:1201 3RD ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1403
Practice Address - Country:US
Practice Address - Phone:575-322-8263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-116791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical