Provider Demographics
NPI:1396433785
Name:PACHECO, MIA G (LMSW)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:G
Last Name:PACHECO
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:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:PENASCO
Mailing Address - State:NM
Mailing Address - Zip Code:87553-0127
Mailing Address - Country:US
Mailing Address - Phone:575-779-4279
Mailing Address - Fax:
Practice Address - Street 1:201 M PUEBLO VIEW ROAD
Practice Address - Street 2:
Practice Address - City:PENASCO
Practice Address - State:NM
Practice Address - Zip Code:87553-0127
Practice Address - Country:US
Practice Address - Phone:575-779-4279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NMSWB-2023-00381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty