Healthcare Provider Details

I. General information

NPI: 1992866842
Provider Name (Legal Business Name): BRUCE BALTO LISW, DCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3417 CARLISLE BLVD. NE
ALBUQUERQUE NM
87110-1648
US

IV. Provider business mailing address

PO BOX 67691
ALBUQUERQUE NM
87193-7691
US

V. Phone/Fax

Practice location:
  • Phone: 505-227-3052
  • Fax: 505-792-4057
Mailing address:
  • Phone: 505-227-3052
  • Fax: 505-792-4057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06300
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: