Provider Demographics
NPI:1922210764
Name:AVALOS, HOMER AVALOS (PHD)
Entity Type:Individual
Prefix:DR
First Name:HOMER
Middle Name:AVALOS
Last Name:AVALOS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300-2 MCCOMBS RD # 16
Mailing Address - Street 2:
Mailing Address - City:CHAPARRAL
Mailing Address - State:NM
Mailing Address - Zip Code:88081-7937
Mailing Address - Country:US
Mailing Address - Phone:915-691-5555
Mailing Address - Fax:
Practice Address - Street 1:336 GERONIMO
Practice Address - Street 2:
Practice Address - City:CHAPPARAL
Practice Address - State:NM
Practice Address - Zip Code:88081
Practice Address - Country:US
Practice Address - Phone:915-691-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1780101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM10061Medicaid