Healthcare Provider Details

I. General information

NPI: 1134555816
Provider Name (Legal Business Name): ELISABETH J KELNER LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2013
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 GUSDORF ROAD, SUITE E SUITE E
TAOS NM
87571
US

IV. Provider business mailing address

4 NACOMA ROAD
EL PRADO NM
87529
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-4297
  • Fax: 575-751-7237
Mailing address:
  • Phone: 575-779-0282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-08071
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: