Healthcare Provider Details

I. General information

NPI: 1215250212
Provider Name (Legal Business Name): JUDY ELLEN RUST-HUERTA LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2010
Last Update Date: 03/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 ALTA VISTA ST
SANTA FE NM
87505-4149
US

IV. Provider business mailing address

PO BOX 23 1100 SOARING EAGLE CT.
CHROMO CO
81128-0023
US

V. Phone/Fax

Practice location:
  • Phone: 505-467-2504
  • Fax:
Mailing address:
  • Phone: 970-264-9203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-07020
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number328987
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: