Healthcare Provider Details

I. General information

NPI: 1174323208
Provider Name (Legal Business Name): EDGAR ALONSO LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W GUTIERREZ
SANTA FE NM
87506-0943
US

IV. Provider business mailing address

PO BOX 601
TESUQUE NM
87574-0601
US

V. Phone/Fax

Practice location:
  • Phone: 347-873-8895
  • Fax:
Mailing address:
  • Phone: 347-873-8895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2025-0188
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: