Healthcare Provider Details

I. General information

NPI: 1518699412
Provider Name (Legal Business Name): CLARICE GREGORY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 UNSER BLVD SE STE C
RIO RANCHO NM
87124-6300
US

IV. Provider business mailing address

12 UNSER BLVD SE STE C
RIO RANCHO NM
87124-6300
US

V. Phone/Fax

Practice location:
  • Phone: 505-636-6100
  • Fax:
Mailing address:
  • Phone: 505-636-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM10572
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: