Healthcare Provider Details

I. General information

NPI: 1164637161
Provider Name (Legal Business Name): SHAYNA YEDRA-SCHAEFER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2007
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 WILMOORE DR SE
ALBUQUERQUE NM
87106-4128
US

IV. Provider business mailing address

1717 WILMOORE DR SE
ALBUQUERQUE NM
87106-4128
US

V. Phone/Fax

Practice location:
  • Phone: 505-720-7702
  • Fax:
Mailing address:
  • Phone: 505-720-7702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06002
License Number StateNM

VIII. Authorized Official

Name: MRS. SHAYNA LEE SCHAEFER
Title or Position: CLINICAL SOCIAL WORKER
Credential: LISW
Phone: 505-720-7702