Healthcare Provider Details

I. General information

NPI: 1184940231
Provider Name (Legal Business Name): JUANITA RAQUEL ZENGERLE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2010
Last Update Date: 01/27/2014
Certification Date:
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

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

V. Phone/Fax

Practice location:
  • Phone: 505-660-5364
  • Fax: 505-474-4663
Mailing address:
  • Phone: 505-660-5364
  • Fax: 505-474-4663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-06738
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-08136
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: