Basic Information
| Provider Information | |||||||||
| NPI: | 1659604627 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALBERT | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | |||||||||
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| Credential: | CHILD WORKER (DAYCAR | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28220 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054715006 | ||||||||
| FaxNumber: | 5058209220 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 TUCUMCARI BLVD | ||||||||
| Address2: | |||||||||
| City: | TUCUMCARI | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754616415 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2009 | ||||||||
| LastUpdateDate: | 09/09/2009 | ||||||||
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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 | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | L7904 | 05 | NM | MEDICAID |