Healthcare Provider Details

I. General information

NPI: 1548803547
Provider Name (Legal Business Name): LATISHA ROYBAL MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 1ST ST NW STE 200
ALBUQUERQUE NM
87102-2311
US

IV. Provider business mailing address

600 1ST ST NW STE 200
ALBUQUERQUE NM
87102-2311
US

V. Phone/Fax

Practice location:
  • Phone: 575-550-7355
  • Fax:
Mailing address:
  • Phone: 505-224-9124
  • Fax: 505-247-9503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberX-11098
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberX11098
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: