Provider Demographics
NPI:1780719658
Name:HEREDIA-SANCHEZ, CRYSTAL (LCSW)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:HEREDIA-SANCHEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W GRIGGS AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1234
Mailing Address - Country:US
Mailing Address - Phone:575-647-2800
Mailing Address - Fax:575-647-2898
Practice Address - Street 1:101 LIVINGSTON LOOP STE C1
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9753
Practice Address - Country:US
Practice Address - Phone:575-824-9000
Practice Address - Fax:866-232-9241
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-064301041C0700X
NMI-064301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18677037Medicaid
NM18677037Medicaid