Basic Information
| Provider Information | |||||||||
| NPI: | 1427402130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HART | ||||||||
| FirstName: | CLAIRA | ||||||||
| MiddleName: | NICHOLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | RBT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RHODES | ||||||||
| OtherFirstName: | CLAIRA | ||||||||
| OtherMiddleName: | NICHOLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 301 PERKINS DR STE B | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756523155 | ||||||||
| FaxNumber: | 5756524104 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 E IDAHO AVE STE 2B | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880014701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755569585 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2016 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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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 | 106S00000X | N | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | RBT-16-23426 | 01 | NM | BEHAVIOR ANALYST CERTIFICATION BOARD CERTIFICATE NUMBER | OTHER | 39177238 | 05 | NM | MEDICAID |