Healthcare Provider Details

I. General information

NPI: 1346312667
Provider Name (Legal Business Name): PHYLLIS M SKOY LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 GEORGIA ST NE BLDG. A SUITE 4
ALBUQUERQUE NM
87110-1359
US

IV. Provider business mailing address

3901 GEORGIA ST NE BLDG. A SUITE 4
ALBUQUERQUE NM
87110-1359
US

V. Phone/Fax

Practice location:
  • Phone: 505-480-8225
  • Fax:
Mailing address:
  • Phone: 505-480-8225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-04570
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: