Healthcare Provider Details

I. General information

NPI: 1831341726
Provider Name (Legal Business Name): JUDITH LEE SHAW LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2008
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 571 BLDG #28
EL RITO NM
87530
US

IV. Provider business mailing address

686 CALLECITA JICARILLA
SANTA FE NM
87505-4940
US

V. Phone/Fax

Practice location:
  • Phone: 575-581-4728
  • Fax: 575-581-0030
Mailing address:
  • Phone: 575-581-4728
  • Fax: 575-581-0030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06403
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: