Provider Demographics
NPI:1801427695
Name:ROUM, STACIA
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:
Last Name:ROUM
Suffix:
Gender:F
Credentials:
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 237
Mailing Address - Street 2:
Mailing Address - City:EL RITO
Mailing Address - State:NM
Mailing Address - Zip Code:87530-0237
Mailing Address - Country:US
Mailing Address - Phone:575-581-4728
Mailing Address - Fax:575-581-0030
Practice Address - Street 1:NM 571 BLDG 28
Practice Address - Street 2:
Practice Address - City:EL RITO
Practice Address - State:NM
Practice Address - Zip Code:87530
Practice Address - Country:US
Practice Address - Phone:575-581-4728
Practice Address - Fax:575-581-0030
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM10379104100000X
NMC-113621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM49475053Medicaid