Basic Information
| Provider Information | |||||||||
| NPI: | 1144731761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEOSES BURCIAGA | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | CARLOS | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2504 CAMINO ENTRADA | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875074851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054715006 | ||||||||
| FaxNumber: | 5058209220 | ||||||||
| Practice Location | |||||||||
| Address1: | 2504 CAMINO ENTRADA | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875074851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054715006 | ||||||||
| FaxNumber: | 5058209220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2017 | ||||||||
| LastUpdateDate: | 09/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 104100000X | M-10237 | NM | N | Behavioral Health & Social Service Providers | Social Worker | 1041S0200X | 372693 | NM | N | Behavioral Health & Social Service Providers | Social Worker | School | 1041C0700X | C-11414 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.