Healthcare Provider Details

I. General information

NPI: 1962790394
Provider Name (Legal Business Name): LYNNE MARIE TREIBEL LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 01/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5345 WYOMING BLVD NE SUITE 200F
ALBUQUERQUE NM
87109-3148
US

IV. Provider business mailing address

5345 WYOMING BLVD NE SUITE 200F
ALBUQUERQUE NM
87109-3148
US

V. Phone/Fax

Practice location:
  • Phone: 505-610-3966
  • Fax: 505-610-3966
Mailing address:
  • Phone: 505-610-3966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-07846
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: