Healthcare Provider Details

I. General information

NPI: 1871587790
Provider Name (Legal Business Name): POLLY H MAFCHIR LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 HARKLE RD STE C
SANTA FE NM
87505-4784
US

IV. Provider business mailing address

PO BOX 194
SANTA FE NM
87504-0194
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-9336
  • Fax: 505-983-7897
Mailing address:
  • Phone: 505-982-9336
  • Fax: 505-983-7897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI-0914
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: