MEDICARE: MRS. EVELYN S. ESTRADA LISW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041S0200X	School Social Worker	I-0634	NM

General Provider Information

NPI Number	:	1295053999
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. EVELYN S. ESTRADA LISW

Provider Business Mailing Address
First Line	:	179 BRIDGE ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-3495
Country	:	US
Telephone Number	:	505-426-2564
Fax Number	:	505-426-2579

Provider Business Practice Location Address
First Line	:	1024 SOUTH PACIFIC
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701
Country	:	US
Telephone Number	:	505-426-2564
Fax Number	:	505-426-2579

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2010
Last Update Date	:	05/06/2010

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