Healthcare Provider Details

I. General information

NPI: 1194891614
Provider Name (Legal Business Name): SUZANNE H. KERSTEN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 LOMAS BLVD NE SUITE 204
ALBUQUERQUE NM
87112-5463
US

IV. Provider business mailing address

10701 LOMAS BLVD NE SUITE 204
ALBUQUERQUE NM
87112-5463
US

V. Phone/Fax

Practice location:
  • Phone: 505-550-9255
  • Fax: 505-298-4900
Mailing address:
  • Phone: 505-550-9255
  • Fax: 505-298-4900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-05378
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: