Healthcare Provider Details

I. General information

NPI: 1134286461
Provider Name (Legal Business Name): THOMAS ROBERT BURNS LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1594 SARA RD SE
RIO RANCHO NM
87124-1862
US

IV. Provider business mailing address

1808 SARATOGA DR NE
RIO RANCHO NM
87144-7822
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-1511
  • Fax:
Mailing address:
  • Phone: 505-771-2005
  • Fax: 505-771-2005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06194
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: