Healthcare Provider Details

I. General information

NPI: 1629199781
Provider Name (Legal Business Name): SHANNON ENRIGHT-SMITH LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9301 INDIAN SCHOOL RD NE STE 103
ALBUQUERQUE NM
87112-2861
US

IV. Provider business mailing address

3 LOS ALAMITOS DR
TIJERAS NM
87059-7701
US

V. Phone/Fax

Practice location:
  • Phone: 505-280-5860
  • Fax: 505-294-3904
Mailing address:
  • Phone: 505-280-5860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06858
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: