Healthcare Provider Details

I. General information

NPI: 1811079239
Provider Name (Legal Business Name): PATTY WYCKOFF-FISH LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 HAWAII AVE
ALAMOGORDO NM
88310-6437
US

IV. Provider business mailing address

707 7TH ST
TULAROSA NM
88352-2617
US

V. Phone/Fax

Practice location:
  • Phone: 505-439-3200
  • Fax: 505-434-1840
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-04645
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number264414
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: