Healthcare Provider Details

I. General information

NPI: 1639595291
Provider Name (Legal Business Name): MELISSA HAGSTRUM LISW PHD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2014
Last Update Date: 03/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W SAN MATEO RD D4
SANTA FE NM
87505-3981
US

IV. Provider business mailing address

6 FRASCO RD
SANTA FE NM
87508-8842
US

V. Phone/Fax

Practice location:
  • Phone: 505-660-0403
  • Fax:
Mailing address:
  • Phone: 505-660-0403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-08107
License Number StateNM

VIII. Authorized Official

Name: DR. MELISSA B. HAGSTRUM
Title or Position: OWNER
Credential: LISW, PHD
Phone: 505-660-0403