Healthcare Provider Details

I. General information

NPI: 1801076930
Provider Name (Legal Business Name): NICOLA M TREVISAN SW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 BENAVIDES RD SW TRUMAN MS
ALBUQUERQUE NM
87121-7910
US

IV. Provider business mailing address

9400 BENAVIDES RD SW TRUMAN MS
ALBUQUERQUE NM
87121-7910
US

V. Phone/Fax

Practice location:
  • Phone: 505-836-3030
  • Fax:
Mailing address:
  • Phone: 505-836-3030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberX 05922
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: