Healthcare Provider Details

I. General information

NPI: 1760839344
Provider Name (Legal Business Name): PETER BIRKHOLZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 CHAPARRAL TRL
SILVER CITY NM
88061-9131
US

IV. Provider business mailing address

13 CHAPARRAL TRL
SILVER CITY NM
88061-9131
US

V. Phone/Fax

Practice location:
  • Phone: 307-254-5648
  • Fax:
Mailing address:
  • Phone: 307-254-5648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3333
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: