Provider Demographics
NPI:1902671225
Name:CORDOVA, ANGELO (LMSW)
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:
Last Name:CORDOVA
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:753 HORIZON VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8651
Mailing Address - Country:US
Mailing Address - Phone:575-200-9375
Mailing Address - Fax:
Practice Address - Street 1:1605 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3117
Practice Address - Country:US
Practice Address - Phone:575-527-0614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2023-1082104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker