Healthcare Provider Details

I. General information

NPI: 1609273713
Provider Name (Legal Business Name): MELANIE JEAN PORTER-KUNZ LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax: 505-256-5416
Mailing address:
  • Phone: 505-265-1711
  • Fax: 505-256-5416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI07190
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number00991456
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: