Provider Demographics
NPI:1992681852
Name:CORDOVA, ANGELA V (LSAA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:V
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-5131
Mailing Address - Country:US
Mailing Address - Phone:575-219-7262
Mailing Address - Fax:
Practice Address - Street 1:3204 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-5131
Practice Address - Country:US
Practice Address - Phone:575-219-7262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2025-0248101Y00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor