Healthcare Provider Details

I. General information

NPI: 1720372972
Provider Name (Legal Business Name): DANIEL JOSEPH MINTIE LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 06/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 WAYNE RD NW
LOS RANCHOS NM
87114-1028
US

IV. Provider business mailing address

312 WAYNE RD NW
LOS RANCHOS NM
87114-1028
US

V. Phone/Fax

Practice location:
  • Phone: 505-792-4519
  • Fax:
Mailing address:
  • Phone: 505-792-4519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06493
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: