Healthcare Provider Details

I. General information

NPI: 1174829170
Provider Name (Legal Business Name): ROXROY ANTHONY REID LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2011
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 CAMINO COLLADO
EDGEWOOD NM
87015-9788
US

IV. Provider business mailing address

25 CAMINO COLLADO
EDGEWOOD NM
87015-9788
US

V. Phone/Fax

Practice location:
  • Phone: 505-710-4278
  • Fax: 505-286-0865
Mailing address:
  • Phone: 505-710-4278
  • Fax: 505-286-0865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: