Provider Demographics
NPI:1659674570
Name:SOLEM, DAVID L (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:L
Last Name:SOLEM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 SANGRE DE CRISTO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1055
Mailing Address - Country:US
Mailing Address - Phone:505-204-6883
Mailing Address - Fax:505-820-9220
Practice Address - Street 1:1107 SANGRE DE CRISTO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1055
Practice Address - Country:US
Practice Address - Phone:505-204-6883
Practice Address - Fax:505-820-9220
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-15
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-07509104100000X
NMC-083111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1082637Medicaid