Healthcare Provider Details

I. General information

NPI: 1275201725
Provider Name (Legal Business Name): TRACY R. FAWVER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 01/14/2026
Certification Date: 01/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5345 WYOMING BLVD NE STE 107
ALBUQUERQUE NM
87109-3193
US

IV. Provider business mailing address

9577 OSUNA RD NE STE B
ALBUQUERQUE NM
87111-2286
US

V. Phone/Fax

Practice location:
  • Phone: 505-238-3345
  • Fax:
Mailing address:
  • Phone: 505-238-3345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-11646
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: