Provider Demographics
NPI:1689127367
Name:ESCARENO-CLARK, CLAUDIA
Entity Type:Individual
Prefix:
First Name:CLAUDIA
Middle Name:
Last Name:ESCARENO-CLARK
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 1:102 N CORONADO AVE
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2700
Mailing Address - Country:US
Mailing Address - Phone:505-629-1813
Mailing Address - Fax:505-753-4123
Practice Address - Street 1:805 EARLY ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1607
Practice Address - Country:US
Practice Address - Phone:505-955-0410
Practice Address - Fax:505-955-8577
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0182121101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM35588519Medicaid