Healthcare Provider Details

I. General information

NPI: 1265527634
Provider Name (Legal Business Name): ABBY LEVERETT BRAUN LISW, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 OLD PECOS TRAIL SUITE P
SANTA FE NM
87505
US

IV. Provider business mailing address

12 BUEN PASTOR
SANTA FE NM
87508
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-2236
  • Fax: 505-466-1257
Mailing address:
  • Phone: 505-820-2236
  • Fax: 505-466-1257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-3023
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: