Basic Information
| Provider Information | |||||||||
| NPI: | 1710310016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOBADILLA | ||||||||
| FirstName: | TONY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S MAIN ST | ||||||||
| Address2: | STE 249 | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880011206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755275884 | ||||||||
| FaxNumber: | 5755275886 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 S MAIN ST | ||||||||
| Address2: | STE 249 | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880011206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755275884 | ||||||||
| FaxNumber: | 5755275886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | M-08350 | NM | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | C-09780 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | C-09780 | 01 | NM | NM REG & LICENSING DEPT | OTHER |