Healthcare Provider Details

I. General information

NPI: 1710445994
Provider Name (Legal Business Name): NATALIE NICOTINE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 03/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 FIVE POINTS RD SW
ALBUQUERQUE NM
87105-3179
US

IV. Provider business mailing address

1528 FIVE POINTS RD SW
ALBUQUERQUE NM
87105-3179
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-6919
  • Fax: 505-242-6929
Mailing address:
  • Phone: 505-242-6919
  • Fax: 505-242-6929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberX-10241
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: