Basic Information
| Provider Information | |||||||||
| NPI: | 1578158473 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAVEZ DE HATLEY | ||||||||
| FirstName: | LARALEA | ||||||||
| MiddleName: | ANTONETTE | ||||||||
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| Credential: | LMSW, BS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5201 VENICE AVE NE STE A | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871132337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059162007 | ||||||||
| FaxNumber: | 5054334490 | ||||||||
| Practice Location | |||||||||
| Address1: | 5201 VENICE AVE NE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059162007 | ||||||||
| FaxNumber: | 5054334490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2021 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | M-11592 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.