Provider Demographics
NPI:1972664480
Name:IRENE, LINDA PATRICE (LMSW)
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:PATRICE
Last Name:IRENE
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 1:1700 CERRILLOS RD
Mailing Address - Street 2:BEHAVIORAL HEALTH
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3554
Mailing Address - Country:US
Mailing Address - Phone:505-946-9460
Mailing Address - Fax:505-983-6243
Practice Address - Street 1:1700 CERRILLOS RD
Practice Address - Street 2:BEHAVIORAL HEALTH
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3554
Practice Address - Country:US
Practice Address - Phone:505-946-9460
Practice Address - Fax:505-983-6243
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-049101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11923032Medicaid
NM8HBR67Medicare PIN
NM8HBR58Medicare PIN
NM11923032Medicaid
NMP99229Medicare ID - Type Unspecified
NM8HBR55Medicare PIN
NM8HBR56Medicare PIN