Healthcare Provider Details

I. General information

NPI: 1336357680
Provider Name (Legal Business Name): DENISE SACCONE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 SOUTH ST FRANCIS DRIVE ROOM 205
SANTA FE NM
87505
US

IV. Provider business mailing address

825 CALLE MEJIA APT 431
SANTA FE NM
87501-1417
US

V. Phone/Fax

Practice location:
  • Phone: 505-501-4410
  • Fax:
Mailing address:
  • Phone: 505-989-1233
  • Fax: 505-989-1233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI04994
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: