Provider Demographics
NPI:1841268158
Name:VARY, VIRGINIA C (LISW)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:C
Last Name:VARY
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12541 INDIAN TRAIL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-4717
Mailing Address - Country:US
Mailing Address - Phone:505-379-7532
Mailing Address - Fax:505-299-1294
Practice Address - Street 1:1400 CARLISLE BLVD NE
Practice Address - Street 2:SUITE C
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5658
Practice Address - Country:US
Practice Address - Phone:505-379-7532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-11
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1681171100000X
NMI064671041C0700X
MI68010165901041C0700X
MIL8633131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM68088311Medicaid