Healthcare Provider Details

I. General information

NPI: 1376776567
Provider Name (Legal Business Name): MARISA B NOCHUMSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2009
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 WILLIAM ST SE
ALBUQUERQUE NM
87102-4661
US

IV. Provider business mailing address

1401 WILLIAM ST SE
ALBUQUERQUE NM
87102-4661
US

V. Phone/Fax

Practice location:
  • Phone: 505-768-5450
  • Fax: 505-842-1185
Mailing address:
  • Phone: 505-768-5450
  • Fax: 505-842-1185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2023-0717
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: