Provider Demographics
NPI:1356069017
Name:NAMBA, YOHTA
Entity type:Individual
Prefix:
First Name:YOHTA
Middle Name:
Last Name:NAMBA
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 1:1911 5TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5403
Mailing Address - Country:US
Mailing Address - Phone:505-955-0410
Mailing Address - Fax:
Practice Address - Street 1:1911 5TH ST STE 100
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5403
Practice Address - Country:US
Practice Address - Phone:505-955-0410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM35588519-6630050Medicaid