Provider Demographics
NPI:1962571158
Name:NOMBERG, BEVERLY A (MSW)
Entity type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:A
Last Name:NOMBERG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 CARLISLE BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5658
Mailing Address - Country:US
Mailing Address - Phone:505-256-9294
Mailing Address - Fax:505-766-9157
Practice Address - Street 1:1400 CARLISLE BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5658
Practice Address - Country:US
Practice Address - Phone:505-256-9294
Practice Address - Fax:505-766-9157
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI10351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM97949Medicaid
NMS5160903Medicare UPIN