Healthcare Provider Details

I. General information

NPI: 1609181429
Provider Name (Legal Business Name): MICHAELA GRANITO-TIBBETTS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 08/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 CAMINO SIERRA VIS
SANTA FE NM
87505-1007
US

IV. Provider business mailing address

7 ESQUINA RD
SANTA FE NM
87508-9172
US

V. Phone/Fax

Practice location:
  • Phone: 505-466-4944
  • Fax: 505-467-2648
Mailing address:
  • Phone: 505-466-4944
  • Fax: 505-467-2648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberM-05778
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: