Healthcare Provider Details

I. General information

NPI: 1245500974
Provider Name (Legal Business Name): TANA HUDSON LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 HIGHWAY 60 BUILDING D
SOCORRO NM
87801-3914
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 575-838-4690
  • Fax: 575-838-4689
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-08462
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: