Provider Demographics
NPI:1740317015
Name:PALMER, DERYL W (LISW)
Entity type:Individual
Prefix:MR
First Name:DERYL
Middle Name:W
Last Name:PALMER
Suffix:
Gender:M
Credentials:LISW
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 6824
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88006-6824
Mailing Address - Country:US
Mailing Address - Phone:575-523-2288
Mailing Address - Fax:575-523-2299
Practice Address - Street 1:2000 E LOHMAN AVE STE C
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3100
Practice Address - Country:US
Practice Address - Phone:575-523-2288
Practice Address - Fax:575-523-2299
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM054231041S0200X
NMI-068591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26782341Medicaid