Provider Demographics
NPI:1962025882
Name:QUEVEDO, RICK J
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:J
Last Name:QUEVEDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-3034
Mailing Address - Country:US
Mailing Address - Phone:505-947-4471
Mailing Address - Fax:
Practice Address - Street 1:6100 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-3034
Practice Address - Country:US
Practice Address - Phone:505-947-4471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM850431989Medicaid