Provider Demographics
NPI:1699300707
Name:VAN TASSLE, EYA SOFIA (LMSW)
Entity type:Individual
Prefix:MRS
First Name:EYA
Middle Name:SOFIA
Last Name:VAN TASSLE
Suffix:
Gender:F
Credentials:LMSW
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 367
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-0367
Mailing Address - Country:US
Mailing Address - Phone:505-660-9185
Mailing Address - Fax:
Practice Address - Street 1:1010 LAS LOMAS RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2634
Practice Address - Country:US
Practice Address - Phone:505-600-1499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-112701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMX-11270OtherLMSW PROVISIONAL LICENSE NUMBER