Healthcare Provider Details

I. General information

NPI: 1245429257
Provider Name (Legal Business Name): ELIZABETH MARIE WIENS LCSW C-10072
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE AVENUE NE BUILDING #2
ALBUQUERQUE NM
87131-1132
US

IV. Provider business mailing address

13104 NEON AVE NE
ALBUQUERQUE NM
87112-4866
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2190
  • Fax:
Mailing address:
  • Phone: 415-319-3824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10072
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: