Provider Demographics
NPI:1457693574
Name:CENTRAL REGION EDUCATIONAL COOPERATIVE
Entity Type:Organization
Organization Name:CENTRAL REGION EDUCATIONAL COOPERATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SLP SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:FUESSEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-889-3412
Mailing Address - Street 1:5323 MENAUL BLVD. NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110
Mailing Address - Country:US
Mailing Address - Phone:505-889-3412
Mailing Address - Fax:505-889-3422
Practice Address - Street 1:5323 MENAUL BLVD. NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-889-3412
Practice Address - Fax:505-889-3422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5290235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1194881565Medicaid