Healthcare Provider Details

I. General information

NPI: 1972640936
Provider Name (Legal Business Name): HENRY SCHELTON LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 LOMA COLORADO ST NE
RIO RANCHO NM
87124-6562
US

IV. Provider business mailing address

9 CIENEGA CANYON RD
PLACITAS NM
87043-9117
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-5618
  • Fax:
Mailing address:
  • Phone: 505-867-4321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberI- 3742
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: