Healthcare Provider Details

I. General information

NPI: 1457391492
Provider Name (Legal Business Name): BHANU JOY HARRISON LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 05/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4308 CARLISLE BLVD NE SUITE 209
ALBUQUERQUE NM
87107-4856
US

IV. Provider business mailing address

4308 CARLISLE BLVD NE SUITE 209
ALBUQUERQUE NM
87107-4856
US

V. Phone/Fax

Practice location:
  • Phone: 505-837-2100
  • Fax: 505-888-7943
Mailing address:
  • Phone: 505-837-2100
  • Fax: 505-888-7943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI5529
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: