Provider Demographics
NPI:1083048037
Name:PICHA, MARY JO (LCSW)
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:PICHA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3524 RIO GRANDE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-3038
Mailing Address - Country:US
Mailing Address - Phone:505-366-9106
Mailing Address - Fax:
Practice Address - Street 1:2611 EUBANK BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1312
Practice Address - Country:US
Practice Address - Phone:505-298-6752
Practice Address - Fax:505-298-6759
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC093961041C0700X
NMX082311041C0700X
NMC-093961041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ7926Medicaid