Healthcare Provider Details

I. General information

NPI: 1104924729
Provider Name (Legal Business Name): DANIEL WAYNE INGROFF LISW LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 FELICIDAD
TAOS NM
87571
US

IV. Provider business mailing address

PO BOX 3107
TAOS NM
87571
US

V. Phone/Fax

Practice location:
  • Phone: 505-737-9348
  • Fax: 505-737-5844
Mailing address:
  • Phone: 505-758-4882
  • Fax: 505-737-5844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI 2149
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: