Provider Demographics
NPI:1194355974
Name:PADILLA, NICOLE MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:PADILLA
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 1:652 VISTA LEJOS LN SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-8980
Mailing Address - Country:US
Mailing Address - Phone:505-397-9034
Mailing Address - Fax:
Practice Address - Street 1:6330 RIVERSIDE PLAZA LN NW STE 260
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-2160
Practice Address - Country:US
Practice Address - Phone:505-226-2839
Practice Address - Fax:505-295-2559
Is Sole Proprietor?:No
Enumeration Date:2020-01-21
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2024-01291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM34183710Medicaid