Healthcare Provider Details

I. General information

NPI: 1154540763
Provider Name (Legal Business Name): ANITA A VIGIL LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 N RIVERSIDE DR
ESPANOLA NM
87532-2811
US

IV. Provider business mailing address

PO BOX 231
ESPANOLA NM
87532-0231
US

V. Phone/Fax

Practice location:
  • Phone: 505-747-0102
  • Fax: 505-753-9758
Mailing address:
  • Phone: 505-747-6809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-1343
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: