Provider Demographics
NPI:1205256179
Name:TAVAREZ-CORRAL, VANESSA (LMSW)
Entity type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:
Last Name:TAVAREZ-CORRAL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 GILMER WAY
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-1505
Mailing Address - Country:US
Mailing Address - Phone:575-528-5127
Mailing Address - Fax:
Practice Address - Street 1:1170 N SOLANO DR STE K
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-2371
Practice Address - Country:US
Practice Address - Phone:575-528-5127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-06539104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker