Healthcare Provider Details

I. General information

NPI: 1225456700
Provider Name (Legal Business Name): LOUISE SELF LM, CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 01/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4916 4TH ST NW
ALBUQUERQUE NM
87107-3949
US

IV. Provider business mailing address

4916 4TH ST NW
ALBUQUERQUE NM
87107-3949
US

V. Phone/Fax

Practice location:
  • Phone: 505-450-2222
  • Fax: 877-500-7949
Mailing address:
  • Phone: 505-450-2222
  • Fax: 877-500-7949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number1412R
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: