Healthcare Provider Details

I. General information

NPI: 1689860462
Provider Name (Legal Business Name): GINA SIMON LISW, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2729 MESILLA ST NE
ALBUQUERQUE NM
87110-3539
US

IV. Provider business mailing address

2729 MESILLA ST NE
ALBUQUERQUE NM
87110-3539
US

V. Phone/Fax

Practice location:
  • Phone: 505-249-8764
  • Fax:
Mailing address:
  • Phone: 505-249-8764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-3207
License Number StateNM

VIII. Authorized Official

Name: GINA SIMON
Title or Position: PRESIDENT
Credential: LISW
Phone: 505-249-8764