Healthcare Provider Details

I. General information

NPI: 1477077253
Provider Name (Legal Business Name): MARIAH ELIZABETH ESPESET LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 RODEO PARK DR W
SANTA FE NM
87505-6351
US

IV. Provider business mailing address

2067 CAMINO LADO
SANTA FE NM
87505-5487
US

V. Phone/Fax

Practice location:
  • Phone: 505-470-6621
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberX-10065
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-11218
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-11137
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: