Healthcare Provider Details

I. General information

NPI: 1972663821
Provider Name (Legal Business Name): KATHLEEN A HALL LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 RIO GRANDE BLVD NW STE A
ALBUQUERQUE NM
87104-3233
US

IV. Provider business mailing address

2501 RIO GRANDE BLVD NW STE A
ALBUQUERQUE NM
87104-3233
US

V. Phone/Fax

Practice location:
  • Phone: 505-321-0794
  • Fax:
Mailing address:
  • Phone: 505-321-0794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-4153
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: