Provider Demographics
NPI:1912224999
Name:CODOVA, ROSE MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:ROSE MARIE
Middle Name:
Last Name:CODOVA
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:PO BOX 1846
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-1846
Mailing Address - Country:US
Mailing Address - Phone:575-758-4224
Mailing Address - Fax:575-751-5219
Practice Address - Street 1:230 ROTTEN TREE ROAD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-1846
Practice Address - Country:US
Practice Address - Phone:575-758-4224
Practice Address - Fax:575-751-5219
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-33521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMM-3352OtherLICENSED MASTERS SOCIAL WORKER