Healthcare Provider Details

I. General information

NPI: 1801129416
Provider Name (Legal Business Name): TAMMY L. WHITE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2595 WEST HIGHWAY 66
GRANTS NM
87020
US

IV. Provider business mailing address

2595 W. HIGHWAY 66
GRANTS NM
87020
US

V. Phone/Fax

Practice location:
  • Phone: 505-285-5451
  • Fax: 505-285-6436
Mailing address:
  • Phone: 505-285-5451
  • Fax: 505-285-6436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-08319
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: