Provider Demographics
NPI:1750676953
Name:TRUJILLO, AMANDA O (MSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:O
Last Name:TRUJILLO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:O
Other - Last Name:TRUJILLO-GONZALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:EL RITO
Mailing Address - State:NM
Mailing Address - Zip Code:87530-0218
Mailing Address - Country:US
Mailing Address - Phone:505-927-3910
Mailing Address - Fax:
Practice Address - Street 1:5 PRIVATE DRIVE 1684
Practice Address - Street 2:
Practice Address - City:EL RITO
Practice Address - State:NM
Practice Address - Zip Code:87530
Practice Address - Country:US
Practice Address - Phone:505-927-3910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-06983104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1750676953Medicaid
NME7436Medicaid