Healthcare Provider Details

I. General information

NPI: 1710207832
Provider Name (Legal Business Name): CAROL WHITE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 06/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 SAN PEDRO DR NE STE 201B
ALBUQUERQUE NM
87110-6749
US

IV. Provider business mailing address

1330 SAN PEDRO DR NE STE 201B
ALBUQUERQUE NM
87110-6749
US

V. Phone/Fax

Practice location:
  • Phone: 505-260-9912
  • Fax: 505-260-9934
Mailing address:
  • Phone: 505-260-9912
  • Fax: 505-260-9934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI-07119
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: