Healthcare Provider Details

I. General information

NPI: 1780666511
Provider Name (Legal Business Name): MARIA GLORIA MUNGUIA WELLMAN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE NE, BUILDING 2
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

202 BRYN MAWR DR NE
ALBUQUERQUE NM
87106-2103
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2190
  • Fax: 505-272-3466
Mailing address:
  • Phone: 505-272-2190
  • Fax: 505-272-3466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-04718
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: