Healthcare Provider Details

I. General information

NPI: 1003692997
Provider Name (Legal Business Name): SUSAN THARPE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2023
Last Update Date: 09/06/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 RODEO DRIVE
LAGUNA NM
87026-0798
US

IV. Provider business mailing address

PO BOX 798
LAGUNA NM
87026-0798
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-9200
  • Fax: 505-552-7294
Mailing address:
  • Phone: 505-552-9200
  • Fax: 505-552-7294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberSWB-2023-0231
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: