Healthcare Provider Details

I. General information

NPI: 1316631054
Provider Name (Legal Business Name): LUISA ANTONIA RODRIGUEZ LMSW, LSSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 SUDDERTH DR STE 210
RUIDOSO NM
88345-6307
US

IV. Provider business mailing address

124 MAPLE DR
RUIDOSO NM
88345-6415
US

V. Phone/Fax

Practice location:
  • Phone: 575-973-7193
  • Fax:
Mailing address:
  • Phone: 575-973-7193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-09516
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: