Healthcare Provider Details

I. General information

NPI: 1790800787
Provider Name (Legal Business Name): ELIZABETH C. TUDOR LCSW C-06550
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 KINGSTON MAIN ST
HILLSBORO NM
88042-9514
US

IV. Provider business mailing address

25 KINGSTON MAIN ST
HILLSBORO NM
88042-9514
US

V. Phone/Fax

Practice location:
  • Phone: 575-313-2385
  • Fax:
Mailing address:
  • Phone: 575-313-2385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-06550
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: