Healthcare Provider Details

I. General information

NPI: 1558370122
Provider Name (Legal Business Name): MICHAEL OLLOM LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 05/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

872 S CAMINO DEL PUEBLO
BERNALILLO NM
87004-5927
US

IV. Provider business mailing address

55 EL CEDRO RD
TIJERAS NM
87059-7429
US

V. Phone/Fax

Practice location:
  • Phone: 505-867-2383
  • Fax: 505-867-7293
Mailing address:
  • Phone: 505-565-1619
  • Fax: 505-565-1620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLISW - I-05823
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: