Healthcare Provider Details

I. General information

NPI: 1669087417
Provider Name (Legal Business Name): MR. TIMOTHY HUGH SCANNELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 09/09/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 UNSER BLVD SE STE 103
RIO RANCHO NM
87124-4660
US

IV. Provider business mailing address

9805 SAN GABRIEL RD NE
ALBUQUERQUE NM
87111-3530
US

V. Phone/Fax

Practice location:
  • Phone: 505-404-0554
  • Fax:
Mailing address:
  • Phone: 505-280-5753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-11654
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: