MEDICARE: MS. IAM JOPHIEL LCSW

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	1041C0700X	Clinical Social Worker	CSW.09927227	CO
2	1041C0700X	Clinical Social Worker	C-09854	NM
3	1041C0700X	Clinical Social Worker	2011035180	MO

General Provider Information

NPI Number	:	1457627614
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. IAM JOPHIEL LCSW

Provider Business Mailing Address
First Line	:	PO BOX 50053
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87181-0053
Country	:	US
Telephone Number	:	314-800-0311
Fax Number	:	314-228-0367

Provider Business Practice Location Address
First Line	:	8045 BIG BEND BLVD, STE 101
Second Line	:
City	:	ST LOUIS
State	:	MO
Zip	:	63119-2714
Country	:	US
Telephone Number	:	314-800-0311
Fax Number	:	314-228-0367

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

Provider Enumeration Date	:	03/31/2012
Last Update Date	:	03/10/2022

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