Provider Demographics
NPI:1588065577
Name:DE AZEVEDO, LAURA (EDS)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DE AZEVEDO
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3338
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87190-3338
Mailing Address - Country:US
Mailing Address - Phone:505-255-5099
Mailing Address - Fax:505-255-4206
Practice Address - Street 1:6020 CONSTITUTION AVE NE
Practice Address - Street 2:SUITE 4
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5900
Practice Address - Country:US
Practice Address - Phone:505-255-5099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-09
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM356440103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool