Provider Demographics
NPI:1972676542
Name:BOATMAN, ROSE M (LISW)
Entity Type:Individual
Prefix:MRS
First Name:ROSE
Middle Name:M
Last Name:BOATMAN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-5218
Mailing Address - Country:US
Mailing Address - Phone:575-885-3082
Mailing Address - Fax:575-885-3082
Practice Address - Street 1:202 E BLODGETT ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-6302
Practice Address - Country:US
Practice Address - Phone:505-628-3034
Practice Address - Fax:505-628-3034
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-050911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM62973762Medicaid
NM00NM00JL25OtherBLUE CROSS BLUE SHIELD
NMNM202650OtherVALUE OPTIONS
NM331425101Medicare ID - Type Unspecified