Healthcare Provider Details

I. General information

NPI: 1043888506
Provider Name (Legal Business Name): REBECCA J CARSON LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2021
Last Update Date: 12/28/2023
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E. 25TH ST.
FARMINGTON NM
87401
US

IV. Provider business mailing address

3401 E. 30TH ST. SUITE A
FARMINGTON NM
87402
US

V. Phone/Fax

Practice location:
  • Phone: 505-599-8612
  • Fax: 855-290-2205
Mailing address:
  • Phone: 505-599-8612
  • Fax: 855-290-2205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberSWB-2023-1222
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: