MEDICARE: MS. MARY COGEN 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-4132	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659409787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY COGEN LISW

Provider Business Mailing Address
First Line	:	1300 CAMINO SIERRA VIS
Second Line	:	ROOM 129
City	:	SANTA FE
State	:	NM
Zip	:	87505-1007
Country	:	US
Telephone Number	:	505-467-2504
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 YUCCA ST
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-5456
Country	:	US
Telephone Number	:	505-467-2996
Fax Number	:

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

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	07/08/2007

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