Healthcare Provider Details

I. General information

NPI: 1427720614
Provider Name (Legal Business Name): SUZETTE URBAN MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 VENICE AVE NE STE A
ALBUQUERQUE NM
87113-2337
US

IV. Provider business mailing address

5201 VENICE AVE NE STE A
ALBUQUERQUE NM
87113-2337
US

V. Phone/Fax

Practice location:
  • Phone: 505-582-4394
  • Fax:
Mailing address:
  • Phone: 505-582-4394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-12186
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: