Basic Information
| Provider Information | |||||||||
| NPI: | 1144768417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | LEASETTE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CONWAY | ||||||||
| OtherFirstName: | LEASETTE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 385 CALLE DE ALEGRA STE A | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755261105 | ||||||||
| FaxNumber: | 5755244266 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 E LISA DR | ||||||||
| Address2: | |||||||||
| City: | CHAPARRAL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5758240820 | ||||||||
| FaxNumber: | 5758241021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2017 | ||||||||
| LastUpdateDate: | 08/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C-11733 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | X-10715 | NM | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | M-10562 | NM | N | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 91656556 | 05 | NM | MEDICAID |