Healthcare Provider Details

I. General information

NPI: 1053187849
Provider Name (Legal Business Name): COLLEEN CLAIRE CILWICK LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2023
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4730 BECKNER RD
SANTA FE NM
87507-3691
US

IV. Provider business mailing address

4730 BECKNER RD
SANTA FE NM
87507-3691
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWB-2023-1096
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: