Healthcare Provider Details

I. General information

NPI: 1699784462
Provider Name (Legal Business Name): ROSALIE DELFINA OBREGON LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 8TH ST
LAS VEGAS NM
87701-4219
US

IV. Provider business mailing address

706 MYRTLE AVE
LAS VEGAS NM
87701-4926
US

V. Phone/Fax

Practice location:
  • Phone: 505-425-6788
  • Fax: 505-425-5408
Mailing address:
  • Phone: 505-425-6788
  • Fax: 505-425-5408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI04789
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: