Healthcare Provider Details

I. General information

NPI: 1154045904
Provider Name (Legal Business Name): FIZZ EHLERT PERKAL LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 CENTRAL AVE SW
ALBUQUERQUE NM
87102-2947
US

IV. Provider business mailing address

1122 CENTRAL AVE SW
ALBUQUERQUE NM
87102-2947
US

V. Phone/Fax

Practice location:
  • Phone: 505-639-5916
  • Fax:
Mailing address:
  • Phone: 505-639-5916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2022-0362
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: