Healthcare Provider Details

I. General information

NPI: 1992833024
Provider Name (Legal Business Name): JOSEPH MARION LACAYO LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 WILLIAMS ST BLDG 15
GALLUP NM
87301-4799
US

IV. Provider business mailing address

758 PATTON DR
GALLUP NM
87301-4784
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-3760
  • Fax: 505-722-0723
Mailing address:
  • Phone: 505-399-8197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-2669
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: