Healthcare Provider Details

I. General information

NPI: 1649304668
Provider Name (Legal Business Name): RICHARD MALCOLM LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 09/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 SEQUOIA RD NW
ALBUQUERQUE NM
87120-1249
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-836-7330
  • Fax:
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-3878
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: