Healthcare Provider Details

I. General information

NPI: 1871968701
Provider Name (Legal Business Name): JOSE FRESQUEZ PHD, LISW/LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2015
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4321 FULCRUM WAY NE STE B
RIO RANCHO NM
87144-8410
US

IV. Provider business mailing address

4321 FULCRUM WAY NE STE B
RIO RANCHO NM
87144-8410
US

V. Phone/Fax

Practice location:
  • Phone: 505-205-6760
  • Fax: 505-867-3514
Mailing address:
  • Phone: 505-205-6760
  • Fax: 505-867-3514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0005
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: