Healthcare Provider Details

I. General information

NPI: 1629783642
Provider Name (Legal Business Name): KELLI TRUEBLOOD-GRAVES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2023
Last Update Date: 01/16/2023
Certification Date: 01/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1056 OSAGE CIR
SANTA FE NM
87505-3325
US

IV. Provider business mailing address

1056 OSAGE CIR
SANTA FE NM
87505-3325
US

V. Phone/Fax

Practice location:
  • Phone: 505-557-5921
  • Fax:
Mailing address:
  • Phone: 505-557-5921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2022-1018
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: