Provider Demographics
NPI:1871968701
Name:FRESQUEZ, JOSE (PHD, LISW/LCSW)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:FRESQUEZ
Suffix:
Gender:M
Credentials:PHD, LISW/LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4321 FULCRUM WAY NE STE B
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-8410
Mailing Address - Country:US
Mailing Address - Phone:505-205-6760
Mailing Address - Fax:505-867-3514
Practice Address - Street 1:4321 FULCRUM WAY NE STE B
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-8410
Practice Address - Country:US
Practice Address - Phone:505-205-6760
Practice Address - Fax:505-867-3514
Is Sole Proprietor?:No
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM00051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical