Healthcare Provider Details

I. General information

NPI: 1376737825
Provider Name (Legal Business Name): MARLENE JOY VELARDE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MARLENE JOY VIGIL

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 SENECA DRIVE
DULCE NM
87528
US

IV. Provider business mailing address

PO BOX 546
DULCE NM
87528-0546
US

V. Phone/Fax

Practice location:
  • Phone: 505-759-3162
  • Fax: 505-759-3588
Mailing address:
  • Phone: 505-759-3162
  • Fax: 505-759-3588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI-05109
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: