Healthcare Provider Details

I. General information

NPI: 1093891319
Provider Name (Legal Business Name): EMERSON S CORLEY LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2006
Last Update Date: 05/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 GEORGIA ST NE STE A4
ALBUQUERQUE NM
87110-1391
US

IV. Provider business mailing address

3901 GEORGIA ST NE STE A4
ALBUQUERQUE NM
87110-1391
US

V. Phone/Fax

Practice location:
  • Phone: 505-322-9057
  • Fax: 505-891-1768
Mailing address:
  • Phone: 505-322-9057
  • Fax: 505-891-1768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-3028
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: