Provider Demographics
NPI:1992833024
Name:LACAYO, JOSEPH MARION (LISW)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:MARION
Last Name:LACAYO
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:758 PATTON DR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4784
Mailing Address - Country:US
Mailing Address - Phone:505-399-8197
Mailing Address - Fax:
Practice Address - Street 1:513 WILLIAMS ST BLDG 15
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4799
Practice Address - Country:US
Practice Address - Phone:505-722-3760
Practice Address - Fax:505-722-0723
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-26691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM56825374Medicaid