Basic Information
| Provider Information | |||||||||
| NPI: | 1932260098 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GACHUPIN | ||||||||
| FirstName: | LENA | ||||||||
| MiddleName: | CORRINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 279 | ||||||||
| Address2: | 110 SHEEP SPRINGS | ||||||||
| City: | JEMEZ PUEBLO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870240279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5758347258 | ||||||||
| FaxNumber: | 5758349507 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 SHEEP SPRINGS WAY | ||||||||
| Address2: | |||||||||
| City: | JEMEZ PUEBLO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5758347258 | ||||||||
| FaxNumber: | 5758349507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 08/24/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I-0591 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 82674060 | 05 | NM | MEDICAID |