Basic Information
Provider Information | |||||||||
NPI: | 1104184266 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WARD | ||||||||
FirstName: | DEZAREE | ||||||||
MiddleName: | TAMARA LEE | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | CSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1900 10TH ST | ||||||||
Address2: |   | ||||||||
City: | ALAMOGORDO | ||||||||
State: | NM | ||||||||
PostalCode: | 883105053 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5754377404 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1900 10TH ST | ||||||||
Address2: |   | ||||||||
City: | ALAMOGORDO | ||||||||
State: | NM | ||||||||
PostalCode: | 883105053 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5757402620 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2012 | ||||||||
LastUpdateDate: | 01/15/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 172V00000X |   |   | Y |   | Other Service Providers | Community Health Worker |   |
ID Information
ID | Type | State | Issuer | Description | 18677037 | 05 | NM |   | MEDICAID |