Healthcare Provider Details

I. General information

NPI: 1053594838
Provider Name (Legal Business Name): SYLVIA M STARR LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 12/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 FRIEDMAN AVE
LAS VEGAS NM
87701-4231
US

IV. Provider business mailing address

3695 HOT SPRINGS BLVD
LAS VEGAS NM
87701-9549
US

V. Phone/Fax

Practice location:
  • Phone: 505-454-5100
  • Fax: 505-454-0397
Mailing address:
  • Phone: 505-454-2100
  • Fax: 505-454-2130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-06013
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: