Healthcare Provider Details

I. General information

NPI: 1023364270
Provider Name (Legal Business Name): RETISHA ANTONIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 SILVER AVE SW
ALBUQUERQUE NM
87102-3123
US

IV. Provider business mailing address

625 SILVER AVE SW
ALBUQUERQUE NM
87102-3123
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-8435
  • Fax:
Mailing address:
  • Phone: 505-842-8435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2026-0902
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: