Healthcare Provider Details

I. General information

NPI: 1447388137
Provider Name (Legal Business Name): LAURA GROSSMAN SW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5341 WYOMING BLVD NE SUITE B
ALBUQUERQUE NM
87109-3164
US

IV. Provider business mailing address

7801 CANDELARIA RD NE SANDIA HS
ALBUQUERQUE NM
87110-3757
US

V. Phone/Fax

Practice location:
  • Phone: 505-508-0197
  • Fax: 505-508-0465
Mailing address:
  • Phone: 505-294-1511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI 5638
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberI 5638
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: