Healthcare Provider Details

I. General information

NPI: 1215917521
Provider Name (Legal Business Name): KIM M ROMERO LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050A 2ND ST SE
KIRTLAND AFB NM
87117-0001
US

IV. Provider business mailing address

933 BRADBURY DR SE
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-933-1482
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-04801
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: