Healthcare Provider Details

I. General information

NPI: 1245734417
Provider Name (Legal Business Name): MARC COMTOIS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3465 MOUNTAIN VIEW BLVD SUITE 13
ANGEL FIRE NM
87710-0756
US

IV. Provider business mailing address

PO BOX 756
ANGEL FIRE NM
87710-0756
US

V. Phone/Fax

Practice location:
  • Phone: 575-613-3361
  • Fax:
Mailing address:
  • Phone: 575-613-3361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10249
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: