Healthcare Provider Details

I. General information

NPI: 1073820122
Provider Name (Legal Business Name): PATRICIA SERNA LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2010
Last Update Date: 09/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16542 HWY 84
CHAMA NM
87520-0617
US

IV. Provider business mailing address

PO BOX 617
CHAMA NM
87520-0617
US

V. Phone/Fax

Practice location:
  • Phone: 575-756-2327
  • Fax: 575-756-1897
Mailing address:
  • Phone: 575-756-2327
  • Fax: 575-756-1897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-0175
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: