Healthcare Provider Details

I. General information

NPI: 1407189459
Provider Name (Legal Business Name): JULIE A HOLBROOK LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 A PASEO DE ONATE
ESPANOLA NM
87532
US

IV. Provider business mailing address

7 AVENIDA VISTA GRANDE # 306
SANTA FE NM
87508-9198
US

V. Phone/Fax

Practice location:
  • Phone: 505-852-1377
  • Fax: 505-852-1378
Mailing address:
  • Phone: 505-466-2260
  • Fax: 505-466-2909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number106027
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: