Healthcare Provider Details

I. General information

NPI: 1992021521
Provider Name (Legal Business Name): CYNTHIA J KELLEY LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 04/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

453 CERRILLOS RD SUITE E
SANTA FE NM
87501-3784
US

IV. Provider business mailing address

453 CERRILLOS RD SUITE E
SANTA FE NM
87501-3784
US

V. Phone/Fax

Practice location:
  • Phone: 505-577-9657
  • Fax: 505-986-3826
Mailing address:
  • Phone: 505-577-9657
  • Fax: 505-986-3826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-07258
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: