Healthcare Provider Details

I. General information

NPI: 1578578019
Provider Name (Legal Business Name): GLENN WOHL LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 69 BOX 47
SAPELLO NM
87745-9604
US

IV. Provider business mailing address

HC 69 BOX 47
SAPELLO NM
87745-9604
US

V. Phone/Fax

Practice location:
  • Phone: 505-454-8381
  • Fax:
Mailing address:
  • Phone: 505-454-8381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-1306
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: