Healthcare Provider Details

I. General information

NPI: 1740797174
Provider Name (Legal Business Name): LESLYE M EAMON PADILLA LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 01/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 PRINCESS JEANNE AVE NE
ALBUQUERQUE NM
87112-4426
US

IV. Provider business mailing address

1321 E POPLAR ST
DEMING NM
88030-4807
US

V. Phone/Fax

Practice location:
  • Phone: 505-830-3128
  • Fax:
Mailing address:
  • Phone: 575-546-5951
  • Fax: 575-546-5994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-3799
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: