Healthcare Provider Details

I. General information

NPI: 1811619471
Provider Name (Legal Business Name): DIANA BLADE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 OFFICE COURT DR STE 102
SANTA FE NM
87507-4903
US

IV. Provider business mailing address

3016 SIRINGO RD
SANTA FE NM
87507-5046
US

V. Phone/Fax

Practice location:
  • Phone: 505-395-9437
  • Fax: 505-930-5427
Mailing address:
  • Phone: 505-310-4682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2022-0733
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: