Healthcare Provider Details

I. General information

NPI: 1366566242
Provider Name (Legal Business Name): RENEE CHRISTINE HEACOX-WINBORN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RENEE CHRISTINE HEACOX LISW

II. Dates (important events)

Enumeration Date: 03/18/2007
Last Update Date: 09/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W HEMLOCK ST
DEMING NM
88030-3622
US

IV. Provider business mailing address

222 S TIN ST
DEMING NM
88030-3645
US

V. Phone/Fax

Practice location:
  • Phone: 575-694-5478
  • Fax:
Mailing address:
  • Phone: 575-694-5478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06900
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: