Healthcare Provider Details

I. General information

NPI: 1164094488
Provider Name (Legal Business Name): STEPHANIE MARIE SALAS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 BROADWAY BLVD NE STE 500
ALBUQUERQUE NM
87102-2367
US

IV. Provider business mailing address

16 RAMADA WAY W
SANTA FE NM
87508-9629
US

V. Phone/Fax

Practice location:
  • Phone: 505-627-1247
  • Fax:
Mailing address:
  • Phone: 505-310-0175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2025-0465
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: