Basic Information
| Provider Information | |||||||||
| NPI: | 1043518046 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA-ROGERS | ||||||||
| FirstName: | ROSE | ||||||||
| MiddleName: | MARY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 271 BIG SKY AVE SW | ||||||||
| Address2: | |||||||||
| City: | LOS LUNAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870316154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057101769 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1218 GRIEGOS RD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871073752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053458471 | ||||||||
| FaxNumber: | 5053425450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2011 | ||||||||
| LastUpdateDate: | 03/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | M-07381 | NM | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.