Healthcare Provider Details

I. General information

NPI: 1932260098
Provider Name (Legal Business Name): LENA CORRINE GACHUPIN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 SHEEP SPRINGS WAY
JEMEZ PUEBLO NM
87024
US

IV. Provider business mailing address

PO BOX 279 110 SHEEP SPRINGS
JEMEZ PUEBLO NM
87024-0279
US

V. Phone/Fax

Practice location:
  • Phone: 575-834-7258
  • Fax: 575-834-9507
Mailing address:
  • Phone: 575-834-7258
  • Fax: 575-834-9507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-0591
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: