Healthcare Provider Details

I. General information

NPI: 1689732224
Provider Name (Legal Business Name): REBECCA LYNNE BERMUDEZ LISW, RIMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 GRANT AVE STE 221
SANTA FE NM
87501-2031
US

IV. Provider business mailing address

128 GRANT AVE STE 221
SANTA FE NM
87501-2031
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-0155
  • Fax: 505-820-0155
Mailing address:
  • Phone: 505-820-0155
  • Fax: 505-820-0155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-04591
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: