Healthcare Provider Details

I. General information

NPI: 1144379744
Provider Name (Legal Business Name): FREDERICK WILLIAM HEYWARD LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 BROADWAY BLVD NE SUITE 103
ALBUQUERQUE NM
87102-2360
US

IV. Provider business mailing address

707 BROADWAY BLVD NE SUITE 103
ALBUQUERQUE NM
87102-2360
US

V. Phone/Fax

Practice location:
  • Phone: 505-766-9361
  • Fax: 505-766-9157
Mailing address:
  • Phone: 505-766-9361
  • Fax: 505-766-9157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-04845
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: