Healthcare Provider Details

I. General information

NPI: 1124095096
Provider Name (Legal Business Name): MARK WILLIAM RAYBOULD LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 INDIAN SCHOOL RD NE
ALBUQUERQUE NM
87106-1825
US

IV. Provider business mailing address

PO BOX 30811
ALBUQUERQUE NM
87190-0811
US

V. Phone/Fax

Practice location:
  • Phone: 505-573-4044
  • Fax: 505-573-4044
Mailing address:
  • Phone: 505-573-4044
  • Fax: 505-573-4044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-04965
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: