Healthcare Provider Details

I. General information

NPI: 1043380041
Provider Name (Legal Business Name): JUDITH ACOSTA LISW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 ROADRUNNER TRAIL
PLACITAS NM
87043
US

IV. Provider business mailing address

16 ROADRUNNER TRAIL
PLACITAS NM
87043
US

V. Phone/Fax

Practice location:
  • Phone: 505-771-2282
  • Fax:
Mailing address:
  • Phone: 505-771-2282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI06292
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0421371
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: