Basic Information
| Provider Information | |||||||||
| NPI: | 1629105960 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HILLEY | ||||||||
| FirstName: | GLENDA | ||||||||
| MiddleName: | FAE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 OAK ST | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753233354 | ||||||||
| FaxNumber: | 5755233354 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 OAK ST | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753233354 | ||||||||
| FaxNumber: | 5755233354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 04/21/2017 | ||||||||
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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 | 1041S0200X | M1605 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | School |
ID Information
| ID | Type | State | Issuer | Description | 28952278 | 05 | NM | MEDICAID |