Healthcare Provider Details

I. General information

NPI: 1487907218
Provider Name (Legal Business Name): BEVERLY TAMANINI LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 1/2 E HILL AVE
GALLUP NM
87301-6153
US

IV. Provider business mailing address

208 1/2 E HILL AVE
GALLUP NM
87301-6153
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-1930
  • Fax:
Mailing address:
  • Phone: 505-863-1930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-07980
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: