Healthcare Provider Details

I. General information

NPI: 1407070980
Provider Name (Legal Business Name): PAMELA ANNE RISLEY MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 EASTGATE DR SUITE 206
LOS ALAMOS NM
87544-3300
US

IV. Provider business mailing address

48 LA PALOMA DR
LOS ALAMOS NM
87544-3434
US

V. Phone/Fax

Practice location:
  • Phone: 505-662-5717
  • Fax: 505-662-5717
Mailing address:
  • Phone: 505-672-9710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI 05566
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: