Healthcare Provider Details

I. General information

NPI: 1023199338
Provider Name (Legal Business Name): SANDRA M FORTIER LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4351 JAGER DR NE SUITE C
RIO RANCHO NM
87144-7523
US

IV. Provider business mailing address

4 CAMINO MESTENO
PLACITAS NM
87043-8623
US

V. Phone/Fax

Practice location:
  • Phone: 505-410-5686
  • Fax:
Mailing address:
  • Phone: 505-771-9279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06875
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: