Healthcare Provider Details

I. General information

NPI: 1942351580
Provider Name (Legal Business Name): GINA SIMON LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2729 MESILLA ST NE
ALBUQUERQUE NM
87110-3539
US

IV. Provider business mailing address

2729 MESILLA ST NE
ALBUQUERQUE NM
87110-3539
US

V. Phone/Fax

Practice location:
  • Phone: 505-249-8764
  • Fax: 505-884-2073
Mailing address:
  • Phone: 505-875-1216
  • Fax: 505-884-2073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-3207
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-3207
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: