Basic Information
| Provider Information | |||||||||
| NPI: | 1114469756 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE VRIES | ||||||||
| FirstName: | BERTHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PHS PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
| FaxNumber: | 5059235354 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 CEDAR ST SE STE 820 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058411434 | ||||||||
| FaxNumber: | 5052222149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2016 | ||||||||
| LastUpdateDate: | 11/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C-09224 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.