Healthcare Provider Details

I. General information

NPI: 1104138874
Provider Name (Legal Business Name): JUDITH G BENT LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2010
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

193 COUNTY ROAD 113
SANTA FE NM
87506-9718
US

IV. Provider business mailing address

193 COUNTY ROAD 113
SANTA FE NM
87506-9718
US

V. Phone/Fax

Practice location:
  • Phone: 505-455-7708
  • Fax:
Mailing address:
  • Phone: 505-455-7708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1-07353
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: