Healthcare Provider Details

I. General information

NPI: 1407105802
Provider Name (Legal Business Name): MIRIAM THORP L.I.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 08/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 OPPENHEIMER DR SUITE 200
LOS ALAMOS NM
87544-2384
US

IV. Provider business mailing address

555 OPPENHEIMER DR SUITE 200
LOS ALAMOS NM
87544-2384
US

V. Phone/Fax

Practice location:
  • Phone: 505-660-5726
  • Fax:
Mailing address:
  • Phone: 505-660-5726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberI04885
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-04885
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: