Healthcare Provider Details

I. General information

NPI: 1629486576
Provider Name (Legal Business Name): TRACY CROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2014
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6121 INDIAN SCHOOL RD NE SUITE 234
ALBUQUERQUE NM
87110-4140
US

IV. Provider business mailing address

10827 HABANERO WAY SE
ALBUQUERQUE NM
87123-4250
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-1362
  • Fax: 505-888-1376
Mailing address:
  • Phone: 505-321-9817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10600
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: