Healthcare Provider Details

I. General information

NPI: 1841482775
Provider Name (Legal Business Name): AMY WESSELL LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 07/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2074 GALISTEO ST STE B4
SANTA FE NM
87505-2157
US

IV. Provider business mailing address

PO BOX 203
GLORIETA NM
87535-0203
US

V. Phone/Fax

Practice location:
  • Phone: 505-629-7698
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06523
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: