Healthcare Provider Details

I. General information

NPI: 1003670167
Provider Name (Legal Business Name): MICHELLE RENEE' MORALES LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2024
Last Update Date: 02/09/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 HASLER VALLEY ROAD
GALLUP NM
87305
US

IV. Provider business mailing address

2504 CAMINO ENTRADA
SANTA FE NM
87507-4851
US

V. Phone/Fax

Practice location:
  • Phone: 505-413-3447
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWB-2024-0049
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: