Healthcare Provider Details

I. General information

NPI: 1194048447
Provider Name (Legal Business Name): ELLEN J SHABSHAI FOX, LISW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2010
Last Update Date: 03/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 CALLE AMELIA
SANTA FE NM
87505-6280
US

IV. Provider business mailing address

2400 CALLE AMELIA
SANTA FE NM
87505-6280
US

V. Phone/Fax

Practice location:
  • Phone: 505-699-4312
  • Fax:
Mailing address:
  • Phone: 505-699-4312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI06240
License Number StateNM

VIII. Authorized Official

Name: MS. ELLEN J SHABSHAI FOX
Title or Position: DIRECTOR
Credential: 5056994312
Phone: 505-699-4312