Healthcare Provider Details

I. General information

NPI: 1124458633
Provider Name (Legal Business Name): AUTUMN DRAGS WOLF LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2013
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11005 SPAIN RD NE STE 15
ALBUQUERQUE NM
87111-1871
US

IV. Provider business mailing address

1035 DON ROMERO DR SW
ALBUQUERQUE NM
87105-3996
US

V. Phone/Fax

Practice location:
  • Phone: 505-715-9673
  • Fax:
Mailing address:
  • Phone: 505-715-9673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-08328
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: