Provider Demographics
NPI:1902440191
Name:VALLEJOS, LORI ANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANNE
Last Name:VALLEJOS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 RIO SAN JOSE
Mailing Address - Street 2:
Mailing Address - City:LAGUNA
Mailing Address - State:NM
Mailing Address - Zip Code:87026
Mailing Address - Country:US
Mailing Address - Phone:505-552-5730
Mailing Address - Fax:
Practice Address - Street 1:7 RIO SAN JOSE
Practice Address - Street 2:
Practice Address - City:LAGUNA
Practice Address - State:NM
Practice Address - Zip Code:87026
Practice Address - Country:US
Practice Address - Phone:505-552-5730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-110151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM106278130OtherNM DRIVERS LICENSE