Healthcare Provider Details

I. General information

NPI: 1013496314
Provider Name (Legal Business Name): SUSANNE CLAIRE LOCKFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 OLD PECOS TRL
SANTA FE NM
87505-4759
US

IV. Provider business mailing address

2336 CAMINO DEL PRADO
SANTA FE NM
87507-4882
US

V. Phone/Fax

Practice location:
  • Phone: 505-424-8777
  • Fax:
Mailing address:
  • Phone: 505-471-1974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number708
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: