Healthcare Provider Details

I. General information

NPI: 1427327352
Provider Name (Legal Business Name): AMY ELIZABETH SPURGIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMY ELIZABETH SPURGIN DESTREE LCSW

II. Dates (important events)

Enumeration Date: 12/21/2011
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
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: 505-986-9633
  • Fax:
Mailing address:
  • Phone: 505-968-9633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number29904
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-07244
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-07244
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: