Provider Demographics
NPI:1477250405
Name:CHAVEZ, LISA M (CSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:ORTEGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12 UNSER BLVD SE STE C
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-6300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 UNSER BLVD SE STE C
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-6300
Practice Address - Country:US
Practice Address - Phone:505-636-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNONE172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55405509Medicaid