Provider Demographics
NPI:1386688224
Name:TRUJILLO, DIANA PATRICIA (LISW)
Entity type:Individual
Prefix:MS
First Name:DIANA
Middle Name:PATRICIA
Last Name:TRUJILLO
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 RODEO PARK DR W
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6351
Mailing Address - Country:US
Mailing Address - Phone:505-553-4242
Mailing Address - Fax:
Practice Address - Street 1:2960 RODEO PARK DR W
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6351
Practice Address - Country:US
Practice Address - Phone:505-553-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-04786104100000X
NMI-067541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM79771882Medicaid