Provider Demographics
NPI:1063055267
Name:JAMES, THEODORA G
Entity type:Individual
Prefix:
First Name:THEODORA
Middle Name:G
Last Name:JAMES
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 1:1000 E AZTEC AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5509
Mailing Address - Country:US
Mailing Address - Phone:505-721-1807
Mailing Address - Fax:505-721-1899
Practice Address - Street 1:1000 E AZTEC AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5509
Practice Address - Country:US
Practice Address - Phone:505-721-1807
Practice Address - Fax:505-721-1899
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-112091041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool