Healthcare Provider Details

I. General information

NPI: 1659409787
Provider Name (Legal Business Name): MARY COGEN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 YUCCA ST
SANTA FE NM
87505-5456
US

IV. Provider business mailing address

1300 CAMINO SIERRA VIS ROOM 129
SANTA FE NM
87505-1007
US

V. Phone/Fax

Practice location:
  • Phone: 505-467-2996
  • Fax:
Mailing address:
  • Phone: 505-467-2504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberI-4132
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: