Provider Demographics
NPI:1912906322
Name:ALLEN, VICKI FULLER (LISW)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:FULLER
Last Name:ALLEN
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 1:530 DE MOSS ST
Mailing Address - Street 2:
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-2618
Mailing Address - Country:US
Mailing Address - Phone:575-542-8384
Mailing Address - Fax:575-542-8387
Practice Address - Street 1:530 DE MOSS ST
Practice Address - Street 2:HILDAGO MEDICAL SERVICES
Practice Address - City:LORDSBURG
Practice Address - State:NM
Practice Address - Zip Code:88045-2618
Practice Address - Country:US
Practice Address - Phone:575-542-8384
Practice Address - Fax:575-542-8387
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI059401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM49878531Medicaid
NM49878531Medicaid