Healthcare Provider Details

I. General information

NPI: 1891993440
Provider Name (Legal Business Name): RUSSELL REESE WYNN LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7007 WYOMING BLVD NE SUITE E-3
ALBUQUERQUE NM
87109-3987
US

IV. Provider business mailing address

7007 WYOMING BLVD NE SUITE E-3
ALBUQUERQUE NM
87109-3987
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-0112
  • Fax: 505-828-1385
Mailing address:
  • Phone: 505-884-0112
  • Fax: 505-828-1385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06600
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: