Healthcare Provider Details

I. General information

NPI: 1790357887
Provider Name (Legal Business Name): ELLEN J SHABSHAI FOX LISW INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2021
Last Update Date: 07/16/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 CALLE AMELIA
SANTA FE NM
87505-6280
US

IV. Provider business mailing address

2400 CALLE AMELIA
SANTA FE NM
87505-6280
US

V. Phone/Fax

Practice location:
  • Phone: 505-699-4312
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: ELLEN FOX
Title or Position: OWNER
Credential:
Phone: 505-699-4312