Healthcare Provider Details

I. General information

NPI: 1508512922
Provider Name (Legal Business Name): LORETTA A. ROYBAL LM SW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2022
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 GUSDORF ROAD, BLDG. E
TAOS NM
87571
US

IV. Provider business mailing address

20 PINE RIDGE DRIVE
LAS VEGAS NM
87701
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-0670
  • Fax: 575-751-3557
Mailing address:
  • Phone: 505-426-7906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-06037
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: