Basic Information
| Provider Information | |||||||||
| NPI: | 1285385781 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLEA | ||||||||
| FirstName: | DAVINA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 416 E HEMAN AVE | ||||||||
| Address2: | |||||||||
| City: | TUCUMCARI | ||||||||
| State: | NM | ||||||||
| PostalCode: | 884012100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5758159426 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1105 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | ARTESIA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882101189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757469848 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2022 | ||||||||
| LastUpdateDate: | 01/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | M-10755 | NM | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.