Provider Demographics
NPI:1851439475
Name:TAFOYA, BREENA S (LISW)
Entity type:Individual
Prefix:MRS
First Name:BREENA
Middle Name:S
Last Name:TAFOYA
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:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:MESILLA PARK
Mailing Address - State:NM
Mailing Address - Zip Code:88047-0727
Mailing Address - Country:US
Mailing Address - Phone:575-642-8046
Mailing Address - Fax:
Practice Address - Street 1:715 E IDAHO AVE STE 2E
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-4701
Practice Address - Country:US
Practice Address - Phone:575-556-9585
Practice Address - Fax:575-556-9456
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM33376824Medicaid