Healthcare Provider Details

I. General information

NPI: 1871538017
Provider Name (Legal Business Name): ELLEN TERESA COSTILLA LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 07/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2741 INDIAN SCHOOL RD NE
ALBUQUERQUE NM
87106-2653
US

IV. Provider business mailing address

580 CARMEL RD
BELEN NM
87002-9200
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-8682
  • Fax: 505-255-7890
Mailing address:
  • Phone: 505-764-6409
  • Fax: 505-764-6455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-04603
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: