Healthcare Provider Details

I. General information

NPI: 1720855828
Provider Name (Legal Business Name): CHARISSE LEVCHAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2023
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4588 PARADISE BLVD NW
ALBUQUERQUE NM
87114
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-998-1717
  • Fax: 505-998-1710
Mailing address:
  • Phone: 505-998-1717
  • Fax: 505-998-1710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2026-0453
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: