Provider Demographics
NPI:1336619493
Name:BUCHANAN, DESARAE NICOLE
Entity Type:Individual
Prefix:
First Name:DESARAE
Middle Name:NICOLE
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 LAWRENCE BLVD TRLR 501
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-6152
Mailing Address - Country:US
Mailing Address - Phone:575-430-7940
Mailing Address - Fax:
Practice Address - Street 1:2800 LAWRENCE BLVD TRLR 501
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6152
Practice Address - Country:US
Practice Address - Phone:575-430-7940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician