Healthcare Provider Details

I. General information

NPI: 1306176219
Provider Name (Legal Business Name): DANIEL MCMAHON EDGERTON LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2009
Last Update Date: 12/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 A SIERRA AZUL
SANTA FE NM
87507
US

IV. Provider business mailing address

PO BOX 5161
SANTA FE NM
87502-5161
US

V. Phone/Fax

Practice location:
  • Phone: 505-629-1887
  • Fax:
Mailing address:
  • Phone: 303-981-1411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-07222
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: