Provider Demographics
NPI:1790267003
Name:CONN, DIANDRA FLORETTA (MSW)
Entity Type:Individual
Prefix:
First Name:DIANDRA
Middle Name:FLORETTA
Last Name:CONN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N WHITE SANDS BLVD
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-6774
Mailing Address - Country:US
Mailing Address - Phone:866-273-2451
Mailing Address - Fax:
Practice Address - Street 1:1200 N WHITE SANDS BLVD
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6774
Practice Address - Country:US
Practice Address - Phone:866-273-2451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NMX-107071041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64434826Medicaid