Healthcare Provider Details

I. General information

NPI: 1114075413
Provider Name (Legal Business Name): SUSAN MARIE NEAL SUSAN NEAL LPAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 LOPEZ RD SW
ALBUQUERQUE NM
87105-3954
US

IV. Provider business mailing address

1101 LOPEZ RD SW
ALBUQUERQUE NM
87105-3954
US

V. Phone/Fax

Practice location:
  • Phone: 505-877-7060
  • Fax:
Mailing address:
  • Phone: 505-877-7060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number0065152
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: