Healthcare Provider Details

I. General information

NPI: 1780773895
Provider Name (Legal Business Name): LORETTA BIFULCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 FAIRVIEW DR. SUITE A
ESPANOLA NM
87532
US

IV. Provider business mailing address

314 DON FERNANDO ST PO DRAWER KK
TAOS NM
87571
US

V. Phone/Fax

Practice location:
  • Phone: 505-747-1991
  • Fax:
Mailing address:
  • Phone: 505-751-7037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0090521
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: