Healthcare Provider Details

I. General information

NPI: 1245685577
Provider Name (Legal Business Name): LAUREL LORD LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAUREL SHAFTER LCSW

II. Dates (important events)

Enumeration Date: 04/23/2016
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 HARKLE RD STE E
SANTA FE NM
87505-4765
US

IV. Provider business mailing address

PO BOX 6880
SANTA FE NM
87502-6880
US

V. Phone/Fax

Practice location:
  • Phone: 505-955-9454
  • Fax: 505-216-9067
Mailing address:
  • Phone: 505-955-9454
  • Fax: 505-216-9067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-62436
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-09884
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: