Healthcare Provider Details

I. General information

NPI: 1992740781
Provider Name (Legal Business Name): TAZUKO ARNOLD LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 10/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 WYOMING BLVD NE SUITE 101
ALBUQUERQUE NM
87112-1035
US

IV. Provider business mailing address

3293 ESPLANADE CIR SE
RIO RANCHO NM
87124-7625
US

V. Phone/Fax

Practice location:
  • Phone: 505-404-0717
  • Fax:
Mailing address:
  • Phone: 505-903-9444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06840
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: