Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 0115311 | NM |
N | 104100000X | Social Worker | M-08562 | NM |
Y | 1041C0700X | Clinical Social Worker | C-10108 | NM |
NPI | 1588003123 |
---|---|
Provider Name | Ms. Maria Inez Bagwell |
First Address | Las Cruces, NM 88005-3423 |
Second Address | Las Cruces, NM 88001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/06/2013 |
Last Update Date | 24/08/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
52379205 | (05) | NM |
620292YRND | MEDICARE (01) | NM |