Basic Information
| Provider Information | |||||||||
| NPI: | 1659674570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOLEM | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.C.S.W | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1107 SANGRE DE CRISTO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875011055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052046883 | ||||||||
| FaxNumber: | 5058209220 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 SANGRE DE CRISTO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875011055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052046883 | ||||||||
| FaxNumber: | 5058209220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2010 | ||||||||
| LastUpdateDate: | 05/04/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | M-07509 | NM | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | C-08311 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1082637 | 05 | NM | MEDICAID |