Healthcare Provider Details

I. General information

NPI: 1669540704
Provider Name (Legal Business Name): REBECCA J POOLE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1138 CARDENAS DR SE
ALBUQUERQUE NM
87108-4809
US

IV. Provider business mailing address

10319 BETTS ST NE
ALBUQUERQUE NM
87112-1533
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-3961
  • Fax: 505-260-2000
Mailing address:
  • Phone: 505-271-6963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-05964
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: