Healthcare Provider Details

I. General information

NPI: 1306279559
Provider Name (Legal Business Name): CLARENCE AARON ENOS LCMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2013
Last Update Date: 04/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 W MALONEY AVE
GALLUP NM
87301-5214
US

IV. Provider business mailing address

PO BOX 3809
GALLUP NM
87305-3809
US

V. Phone/Fax

Practice location:
  • Phone: 505-870-1483
  • Fax:
Mailing address:
  • Phone: 505-863-3377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-07770
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-10430
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: