Healthcare Provider Details

I. General information

NPI: 1649500554
Provider Name (Legal Business Name): KENNETH BRUCE WINFREY LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2009
Last Update Date: 12/07/2024
Certification Date: 12/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 SAN PEDRO DR NE SUITE 201-B
ALBUQUERQUE NM
87110-6744
US

IV. Provider business mailing address

3150 CARLISLE BLVD NE STE 105
ALBUQUERQUE NM
87110-1680
US

V. Phone/Fax

Practice location:
  • Phone: 505-410-1379
  • Fax:
Mailing address:
  • Phone: 505-410-1379
  • Fax: 505-207-7421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-07767
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: