Provider Demographics
NPI:1588912893
Name:DIVETT, WILLIAM JACOB (LISW)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JACOB
Last Name:DIVETT
Suffix:
Gender:M
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:PO BOX 843
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-0843
Mailing Address - Country:US
Mailing Address - Phone:575-356-6695
Mailing Address - Fax:575-356-5948
Practice Address - Street 1:1515 W FIR ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-5703
Practice Address - Country:US
Practice Address - Phone:575-356-6695
Practice Address - Fax:575-356-5948
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI08039104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker