Healthcare Provider Details

I. General information

NPI: 1003837568
Provider Name (Legal Business Name): VIRGINIA A ALLEN L.I.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N 2ND ST
RATON NM
87740-3803
US

IV. Provider business mailing address

101 N 2ND ST
RATON NM
87740-3803
US

V. Phone/Fax

Practice location:
  • Phone: 505-445-7090
  • Fax: 505-445-7663
Mailing address:
  • Phone: 505-445-7090
  • Fax: 505-445-7663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberI-05743
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: