Provider Demographics
NPI:1760065817
Name:CHAVEZ, TANA
Entity Type:Individual
Prefix:
First Name:TANA
Middle Name:
Last Name:CHAVEZ
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 1:9201 MONTGOMERY BLVD NE STE 5
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2468
Mailing Address - Country:US
Mailing Address - Phone:505-217-1717
Mailing Address - Fax:
Practice Address - Street 1:P.O BOX 4339
Practice Address - Street 2:
Practice Address - City:SAN FELIPE PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87001
Practice Address - Country:US
Practice Address - Phone:505-771-1463
Practice Address - Fax:505-771-9994
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1115175T00000X
NMCSA0223991101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM21720827Medicaid