Healthcare Provider Details

I. General information

NPI: 1265442487
Provider Name (Legal Business Name): JOHNNY MARTIN LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 10TH ST
ALAMOGORDO NM
88310-5053
US

IV. Provider business mailing address

1900 10TH ST
ALAMOGORDO NM
88310-5053
US

V. Phone/Fax

Practice location:
  • Phone: 505-437-7404
  • Fax: 505-439-2860
Mailing address:
  • Phone: 505-437-7404
  • Fax: 505-439-2860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-3203
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: