Basic Information
| Provider Information | |||||||||
| NPI: | 1952621070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROMERO | ||||||||
| FirstName: | ERICA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2551 COORS BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871201213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053383320 | ||||||||
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| Practice Location | |||||||||
| Address1: | 260 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 884352006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059678082 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2010 | ||||||||
| LastUpdateDate: | 03/08/2016 | ||||||||
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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 | 1041C0700X | C-09214 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | M-07540 | NM | N | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 03129543 | 05 | NM | MEDICAID |