Provider Demographics
NPI:1770169054
Name:DITTEL, SERRA RAQUEL (LMSW)
Entity type:Individual
Prefix:
First Name:SERRA
Middle Name:RAQUEL
Last Name:DITTEL
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 1:39C RANCHOS CANONCITO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-9520
Mailing Address - Country:US
Mailing Address - Phone:503-857-5184
Mailing Address - Fax:
Practice Address - Street 1:39C RANCHOS CANONCITO
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-9520
Practice Address - Country:US
Practice Address - Phone:503-857-5184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-09830104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker