Healthcare Provider Details

I. General information

NPI: 1497146690
Provider Name (Legal Business Name): SCOTT TEMPLE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 NM HIGHWAY 50
PECOS NM
87552
US

IV. Provider business mailing address

44 SETON VILLAGE RD
SANTA FE NM
87508-8153
US

V. Phone/Fax

Practice location:
  • Phone: 505-757-6482
  • Fax:
Mailing address:
  • Phone: 505-699-5261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-08994
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: