Healthcare Provider Details

I. General information

NPI: 1083048037
Provider Name (Legal Business Name): MARY JO PICHA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2013
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 EUBANK BLVD NE
ALBUQUERQUE NM
87112-1312
US

IV. Provider business mailing address

3524 RIO GRANDE BLVD NW
ALBUQUERQUE NM
87107-3038
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-6752
  • Fax: 505-298-6759
Mailing address:
  • Phone: 505-366-9106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC09396
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX08231
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberC-09396
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: