Provider Demographics
NPI:1710136726
Name:BECENTI-FUNDARK, TWILA (LISW)
Entity Type:Individual
Prefix:MS
First Name:TWILA
Middle Name:
Last Name:BECENTI-FUNDARK
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 S MILLER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6463
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 S. MILLER
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5617
Practice Address - Country:US
Practice Address - Phone:505-566-0515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-42241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical