Healthcare Provider Details

I. General information

NPI: 1477675460
Provider Name (Legal Business Name): DENISE M RAVEN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 09/17/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2917 CARLISLE BLVD NE STE 105
ALBUQUERQUE NM
87110-2489
US

IV. Provider business mailing address

2917 CARLISLE BLVD NE STE 105
ALBUQUERQUE NM
87110-2489
US

V. Phone/Fax

Practice location:
  • Phone: 505-269-0212
  • Fax: 505-312-8684
Mailing address:
  • Phone: 505-269-0212
  • Fax: 505-312-8684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-04926
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: