Healthcare Provider Details

I. General information

NPI: 1619068129
Provider Name (Legal Business Name): PATRICIA A. MOURANT LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 WYOMING BLVD NE BLDG. C, SUITE 105
ALBUQUERQUE NM
87109-3932
US

IV. Provider business mailing address

1843 FIELD DR NE
ALBUQUERQUE NM
87112-2833
US

V. Phone/Fax

Practice location:
  • Phone: 505-821-9700
  • Fax: 505-821-9646
Mailing address:
  • Phone: 505-328-0651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-3614
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: