Provider Demographics
NPI:1811501323
Name:CDEBACA, KRYSTAL MARYLOU (LMSW)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:MARYLOU
Last Name:CDEBACA
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 1:767 DON GALLEGOS CIR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-8927
Mailing Address - Country:US
Mailing Address - Phone:505-426-6117
Mailing Address - Fax:
Practice Address - Street 1:2528 RIDGE RUNNER RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4971
Practice Address - Country:US
Practice Address - Phone:505-425-2622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-11253104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker