Provider Demographics
NPI:1477681195
Name:KLASTORIN, MARY BETH (SW)
Entity type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:KLASTORIN
Suffix:
Gender:F
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8400 BARSTOW ST NE
Mailing Address - Street 2:DESERT RIDGE ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-2832
Mailing Address - Country:US
Mailing Address - Phone:505-857-9282
Mailing Address - Fax:
Practice Address - Street 1:8400 BARSTOW ST NE
Practice Address - Street 2:DESERT RIDGE ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-2832
Practice Address - Country:US
Practice Address - Phone:505-857-9282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI 3104104100000X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMJ 9901Medicaid