Healthcare Provider Details

I. General information

NPI: 1225362627
Provider Name (Legal Business Name): JAN PHILIP STANLEY MSSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 10/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TANO ESCONDIDO
SANTA FE NM
87506-7512
US

IV. Provider business mailing address

#1 TANO ESCONDIDO
SANTA FE NM
87506
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-2277
  • Fax: 505-476-2320
Mailing address:
  • Phone: 505-983-2277
  • Fax: 505-476-2320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-1927
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: