Basic Information
| Provider Information | |||||||||
| NPI: | 1194877308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELIZALDE | ||||||||
| FirstName: | TIMOTHEA | ||||||||
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| Credential: | SW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 COAL AVE SE | ||||||||
| Address2: | HIGHLAND HS | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871082804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052653711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4700 COAL AVE SE | ||||||||
| Address2: | HIGHLAND HS | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871082804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052653711 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | M 2819 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | School |
ID Information
| ID | Type | State | Issuer | Description | 28480040 | 05 | NM | MEDICAID |