Healthcare Provider Details

I. General information

NPI: 1407123789
Provider Name (Legal Business Name): MARK OVRICK LISW LSSW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2011
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1096 MECHEM DR SUITE 202
RUIDOSO NM
88345-7067
US

IV. Provider business mailing address

1096 MECHEM DR SUITE 202
RUIDOSO NM
88345-7067
US

V. Phone/Fax

Practice location:
  • Phone: 575-808-8380
  • Fax: 575-808-8380
Mailing address:
  • Phone: 575-808-8380
  • Fax: 575-808-8380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-05300
License Number StateNM

VIII. Authorized Official

Name: MARK OVRICK
Title or Position: LICENSED INDEPENDENT SOCIAL WORKER
Credential: LISW
Phone: 575-937-5643