Healthcare Provider Details

I. General information

NPI: 1841268158
Provider Name (Legal Business Name): VIRGINIA C VARY LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2006
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 CARLISLE BLVD NE SUITE C
ALBUQUERQUE NM
87110-5658
US

IV. Provider business mailing address

12541 INDIAN TRAIL NE
ALBUQUERQUE NM
87112-4717
US

V. Phone/Fax

Practice location:
  • Phone: 505-379-7532
  • Fax:
Mailing address:
  • Phone: 505-379-7532
  • Fax: 505-299-1294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1681
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI06467
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801016590
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL863313
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: