Healthcare Provider Details

I. General information

NPI: 1912950999
Provider Name (Legal Business Name): KENNETH W HODDER LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 ALAMEDA BLVD NW
ALBUQUERQUE NM
87114-1937
US

IV. Provider business mailing address

1100 ALAMEDA BLVD NW
ALBUQUERQUE NM
87114-1937
US

V. Phone/Fax

Practice location:
  • Phone: 505-897-7883
  • Fax: 505-792-8578
Mailing address:
  • Phone: 505-897-7883
  • Fax: 505-792-8578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI-2148
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: