Healthcare Provider Details

I. General information

NPI: 1902821911
Provider Name (Legal Business Name): ELISABETH E MASSARO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 ZOZOBRA LN
SANTA FE NM
87505-6100
US

IV. Provider business mailing address

PO BOX 6338
SANTA FE NM
87502-6338
US

V. Phone/Fax

Practice location:
  • Phone: 505-577-5758
  • Fax:
Mailing address:
  • Phone: 505-438-2612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI05491
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: