Healthcare Provider Details

I. General information

NPI: 1194949545
Provider Name (Legal Business Name): CAMILLE GREEN SW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 SUNSHINE TER SE LOWELL ES
ALBUQUERQUE NM
87106-3906
US

IV. Provider business mailing address

1700 SUNSHINE TER SE LOWELL ES
ALBUQUERQUE NM
87106-3906
US

V. Phone/Fax

Practice location:
  • Phone: 505-764-2011
  • Fax:
Mailing address:
  • Phone: 505-764-2011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberM 5700
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: