Healthcare Provider Details

I. General information

NPI: 1306150024
Provider Name (Legal Business Name): MADELYN KRASSNER LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2010
Last Update Date: 08/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 LETRADO ST
SANTA FE NM
87505-4146
US

IV. Provider business mailing address

605 LETRADO ST
SANTA FE NM
87505-4146
US

V. Phone/Fax

Practice location:
  • Phone: 505-470-1775
  • Fax: 505-476-2694
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberI-3496
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: