Healthcare Provider Details

I. General information

NPI: 1104973155
Provider Name (Legal Business Name): RICHARD J VINNAY LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RICK VINNAY LISW

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6211 SAN MATEO BLVD NE SUITE 170
ALBUQUERQUE NM
87109-3533
US

IV. Provider business mailing address

PO BOX 961
CEDAR CREST NM
87008-0961
US

V. Phone/Fax

Practice location:
  • Phone: 505-263-3942
  • Fax: 505-816-6702
Mailing address:
  • Phone: 505-263-3942
  • Fax: 505-816-6702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI4335
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: