Basic Information
| Provider Information | |||||||||
| NPI: | 1912657032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROMERO, | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRUBELNIK | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 907 | ||||||||
| Address2: | |||||||||
| City: | HOBBS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882410907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753933168 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 110 E MESCALERO RD | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882016542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757552272 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2022 | ||||||||
| LastUpdateDate: | 07/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | SWB-2022-0172 | NM | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 42775728 | 05 | NM | MEDICAID |