Healthcare Provider Details

I. General information

NPI: 1427219716
Provider Name (Legal Business Name): FAYETTE LYNN BARBOUR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 MARTHA ST NE
ALBUQUERQUE NM
87112-4362
US

IV. Provider business mailing address

PO BOX 11322
ALBUQUERQUE NM
87192-0322
US

V. Phone/Fax

Practice location:
  • Phone: 505-321-9828
  • Fax:
Mailing address:
  • Phone: 505-321-9828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC05380
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI05380
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: