Healthcare Provider Details

I. General information

NPI: 1689007627
Provider Name (Legal Business Name): ROBERT E. KRISTY MSW, MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 08/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1532 CERRILLOS RD BUILDING B
SANTA FE NM
87505-3512
US

IV. Provider business mailing address

2415 SAN PATRICIO PLZ
SANTA FE NM
87505-5834
US

V. Phone/Fax

Practice location:
  • Phone: 505-944-1364
  • Fax:
Mailing address:
  • Phone: 240-463-2104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-08307
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: