Healthcare Provider Details

I. General information

NPI: 1386836344
Provider Name (Legal Business Name): JANICE FAYE BAILEY LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 LAS LOMAS RD NE SUITE 3-4
ALBUQUERQUE NM
87102-2634
US

IV. Provider business mailing address

1131 FLORIDA ST SE
ALBUQUERQUE NM
87108-4931
US

V. Phone/Fax

Practice location:
  • Phone: 505-246-8700
  • Fax: 505-246-8706
Mailing address:
  • Phone: 505-506-0044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06549
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: