Healthcare Provider Details

I. General information

NPI: 1679808158
Provider Name (Legal Business Name): EUGENE WELLS LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2009
Last Update Date: 10/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3824 CORRALES RD
CORRALES NM
87048-9306
US

IV. Provider business mailing address

505 2ND ST SW #1
ALBUQUERQUE NM
87102-3970
US

V. Phone/Fax

Practice location:
  • Phone: 505-804-5457
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI06224
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: