Provider Demographics
NPI:1215057096
Name:TETRUEALT, DENISE (SW)
Entity type:Individual
Prefix:MS
First Name:DENISE
Middle Name:
Last Name:TETRUEALT
Suffix:
Gender:F
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PRICE RANCH RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-9597
Mailing Address - Country:US
Mailing Address - Phone:505-466-4184
Mailing Address - Fax:
Practice Address - Street 1:10 PRICE RANCH RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-9597
Practice Address - Country:US
Practice Address - Phone:505-466-4184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-051461041S0200X
NMC-065731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26178516Medicaid