Healthcare Provider Details

I. General information

NPI: 1760797666
Provider Name (Legal Business Name): BEVERLY ANN WOODBURY LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2010
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 HOB RD
LOS LUNAS NM
87031-7601
US

IV. Provider business mailing address

PO BOX 270
PERALTA NM
87042-0270
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-3092
  • Fax: 505-865-7721
Mailing address:
  • Phone: 505-865-6176
  • Fax: 505-865-3268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-04633
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: