Healthcare Provider Details

I. General information

NPI: 1336297803
Provider Name (Legal Business Name): EDWARD HOWARD DAPO III MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 04/04/2019

III. Provider practice location address

119 LUNA AVENUE
LOS LUNAS NM
87031
US

IV. Provider business mailing address

PO BOX 1027
LOS LUNAS NM
87031-1027
US

V. Phone/Fax

Practice location:
  • Phone: 505-203-6614
  • Fax:
Mailing address:
  • Phone: 505-203-6614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number253680
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: