Basic Information
| Provider Information | |||||||||
| NPI: | 1780719658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEREDIA-SANCHEZ | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | |||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 W GRIGGS AVE | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880011234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756472800 | ||||||||
| FaxNumber: | 5756472898 | ||||||||
| Practice Location | |||||||||
| Address1: | 880 ANTHONY DRIVE | ||||||||
| Address2: | SUITE 8A | ||||||||
| City: | ANTHONY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5752015136 | ||||||||
| FaxNumber: | 5752015141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 02/17/2015 | ||||||||
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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 | 1041C0700X | I-06430 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 18677037 | 05 | NM | MEDICAID |