Basic Information
Provider Information
NPI: 1003140559
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WILSON
FirstName: BATES
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 404 HUNTER ST
Address2:  
City: ESPANOLA
State: NM
PostalCode: 875322655
CountryCode: US
TelephoneNumber: 5057534123
FaxNumber: 5057536947
Practice Location
Address1: 404 HUNTER ST
Address2:  
City: ESPANOLA
State: NM
PostalCode: 875322655
CountryCode: US
TelephoneNumber: 5057534123
FaxNumber: 5057536947
Other Information
ProviderEnumerationDate: 09/30/2009
LastUpdateDate: 10/08/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
104100000X  Y Behavioral Health & Social Service ProvidersSocial Worker 

ID Information
IDTypeStateIssuerDescription
E743605NM MEDICAID


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