Healthcare Provider Details

I. General information

NPI: 1144451766
Provider Name (Legal Business Name): GUSTAVO GONZALEZ LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2009
Last Update Date: 12/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 GUSDORF ROAD, SUITE M
TAOS NM
87571-6671
US

IV. Provider business mailing address

1337 GUSDORF RD STE M PO BOX 2238
TAOS NM
87571-7200
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI 3441
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: