Healthcare Provider Details

I. General information

NPI: 1730312489
Provider Name (Legal Business Name): MARY JO H SHORTES LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY JO HEIMBIGNER MSW

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#1 FOSTER ROAD
RESERVE NM
87830
US

IV. Provider business mailing address

PO BOX 710
RESERVE NM
87830-0710
US

V. Phone/Fax

Practice location:
  • Phone: 575-533-6456
  • Fax: 575-533-6767
Mailing address:
  • Phone: 575-533-6456
  • Fax: 575-533-6767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06997
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: