Provider Demographics
NPI:1790092054
Name:WETHINGTON, VICKIE LYNNE (LMSW)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:LYNNE
Last Name:WETHINGTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 ANDREA DR
Mailing Address - Street 2:SUITE 4, BUILDING E
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6726
Mailing Address - Country:US
Mailing Address - Phone:505-324-5855
Mailing Address - Fax:505-324-5896
Practice Address - Street 1:851 ANDREA DR
Practice Address - Street 2:SUITE 4, BUIDLING E
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6726
Practice Address - Country:US
Practice Address - Phone:505-324-5855
Practice Address - Fax:505-324-5896
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMB-04623104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker