Provider Demographics
NPI:1730118670
Name:EVERSOLE, NANCY D (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:D
Last Name:EVERSOLE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4236 CALLE CAZUELA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-7159
Mailing Address - Country:US
Mailing Address - Phone:505-473-7682
Mailing Address - Fax:
Practice Address - Street 1:2753 STATE ROAD 522
Practice Address - Street 2:
Practice Address - City:QUESTA
Practice Address - State:NM
Practice Address - Zip Code:87556
Practice Address - Country:US
Practice Address - Phone:575-586-0315
Practice Address - Fax:575-586-0519
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-40311041C0700X
NMC-40311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM30821274Medicaid
NM30821274Medicaid