Healthcare Provider Details

I. General information

NPI: 1164516266
Provider Name (Legal Business Name): CHARLES JOSEPH SWIERKOSZ M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MABOUD CHARLES JOSEPH SWIERKOSZ

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 OLD PECOS TRL SUITE E
SANTA FE NM
87505-4706
US

IV. Provider business mailing address

1751 OLD PECOS TRAIL SUITE E
SANTA FE NM
87505
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-4131
  • Fax: 505-992-6145
Mailing address:
  • Phone: 505-988-4131
  • Fax: 505-992-6145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0215
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: