Provider Demographics
NPI:1770807323
Name:MACIAS, AMBER K (BA, DS II)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:K
Last Name:MACIAS
Suffix:
Gender:F
Credentials:BA, DS II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 MENAUL BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-1614
Mailing Address - Country:US
Mailing Address - Phone:505-459-5899
Mailing Address - Fax:
Practice Address - Street 1:1111 MENAUL BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1614
Practice Address - Country:US
Practice Address - Phone:505-459-5899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM251S00000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM172V00000XMedicaid