Healthcare Provider Details

I. General information

NPI: 1699188995
Provider Name (Legal Business Name): INA TOWNLEY BAWAYA LCSW, MFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: INA LEE TOWNLEY

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 02/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 GEORGIA ST NE STE A4
ALBUQUERQUE NM
87110-1391
US

IV. Provider business mailing address

12820 THOMTE RD NE
ALBUQUERQUE NM
87112-6808
US

V. Phone/Fax

Practice location:
  • Phone: 505-803-7150
  • Fax: 505-293-0617
Mailing address:
  • Phone: 505-293-2768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-08584
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: