Healthcare Provider Details

I. General information

NPI: 1275730434
Provider Name (Legal Business Name): ROBERT DOUGLAS ZETTERVALL LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6303 INDIAN SCHOOL RD NE APARTMENT #307
ALBUQUERQUE NM
87110-5328
US

IV. Provider business mailing address

6303 INDIAN SCHOOL RD NE APARTMENT #307
ALBUQUERQUE NM
87110-5328
US

V. Phone/Fax

Practice location:
  • Phone: 505-881-4120
  • Fax:
Mailing address:
  • Phone: 505-881-4120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-0586
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: