Healthcare Provider Details

I. General information

NPI: 1942639646
Provider Name (Legal Business Name): KIRSTEN STEVENS WING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2013
Last Update Date: 11/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2724 ALAMOSA DR
SANTA FE NM
87505-5234
US

IV. Provider business mailing address

2724 ALAMOSA DR
SANTA FE NM
87505-5234
US

V. Phone/Fax

Practice location:
  • Phone: 512-228-8029
  • Fax: 505-213-0101
Mailing address:
  • Phone: 512-228-8029
  • Fax: 505-213-0101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-08666
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: