Healthcare Provider Details

I. General information

NPI: 1437673985
Provider Name (Legal Business Name): SERA ANAH NOLAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 AGUA FRIA ST APT B
SANTA FE NM
87505-0702
US

IV. Provider business mailing address

1800 AGUA FRIA ST APT B
SANTA FE NM
87505-0702
US

V. Phone/Fax

Practice location:
  • Phone: 312-576-2667
  • Fax:
Mailing address:
  • Phone: 312-576-2667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10016
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: