Healthcare Provider Details

I. General information

NPI: 1710171137
Provider Name (Legal Business Name): CAROLYN REED GRIFFIN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 08/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CONSTITUTION NE CONSULT LIASION SERVICE
ALBUQUERQUE NM
87112
US

IV. Provider business mailing address

4601 BREECE RD SW
ALBUQUERQUE NM
87105-6405
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-2134
  • Fax:
Mailing address:
  • Phone: 505-873-1270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-0455
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: