Healthcare Provider Details

I. General information

NPI: 1285948851
Provider Name (Legal Business Name): TERRY R SMITH LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2010
Last Update Date: 08/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3904 67TH ST NW
ALBUQUERQUE NM
87120-4935
US

IV. Provider business mailing address

3904 67TH ST NW
ALBUQUERQUE NM
87120-4935
US

V. Phone/Fax

Practice location:
  • Phone: 505-836-1178
  • Fax:
Mailing address:
  • Phone: 505-836-1178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-2680
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: