Healthcare Provider Details

I. General information

NPI: 1679220693
Provider Name (Legal Business Name): LINDA A IONTA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 LINDA DR
GALLUP NM
87301-5619
US

IV. Provider business mailing address

1611 LINDA DR
GALLUP NM
87301-5619
US

V. Phone/Fax

Practice location:
  • Phone: 505-870-6514
  • Fax:
Mailing address:
  • Phone: 505-870-6514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-0817
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: