Healthcare Provider Details

I. General information

NPI: 1174593586
Provider Name (Legal Business Name): BART J. LEUSER LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 12/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE NE BUILDING 2
ALBUQUERQUE NM
87131-5391
US

IV. Provider business mailing address

2600 MARBLE NE BUILDING 2
ALBUQUERQUE NM
87131-5391
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5022
  • Fax: 505-272-3466
Mailing address:
  • Phone: 505-272-5022
  • Fax: 505-272-3466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-4152
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: