Healthcare Provider Details

I. General information

NPI: 1952189656
Provider Name (Legal Business Name): LORETTA CORDOVA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2023
Last Update Date: 09/15/2023
Certification Date: 09/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LASER RD NE
RIO RANCHO NM
87124-4517
US

IV. Provider business mailing address

500 LASER RD NE
RIO RANCHO NM
87124-4517
US

V. Phone/Fax

Practice location:
  • Phone: 505-962-1242
  • Fax:
Mailing address:
  • Phone: 505-962-1242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberM-2815
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: