Healthcare Provider Details

I. General information

NPI: 1326110198
Provider Name (Legal Business Name): SYLVIE M EYRAL LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 SAN JOSE AVENUE
SANTA FE NM
87505
US

IV. Provider business mailing address

1301 SAN JOSE AVE
SANTA FE NM
87505
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-9109
  • Fax: 505-954-4744
Mailing address:
  • Phone: 505-984-9109
  • Fax: 505-954-4744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI2657
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: