Healthcare Provider Details

I. General information

NPI: 1558517037
Provider Name (Legal Business Name): REBECCA GRACE LARIVEE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2008
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W CHACO ST
AZTEC NM
87410-1913
US

IV. Provider business mailing address

PO BOX 1173
FLORA VISTA NM
87415-1173
US

V. Phone/Fax

Practice location:
  • Phone: 505-566-0319
  • Fax:
Mailing address:
  • Phone: 505-360-0594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06476
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberI-06476
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: