Healthcare Provider Details

I. General information

NPI: 1619909207
Provider Name (Legal Business Name): STEPHANIE A. GUTZ LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 11/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 GUSDORF RD. SUITE E
TAOS NM
87571-6499
US

IV. Provider business mailing address

PO BOX 1077
EL PRADO NM
87529-1077
US

V. Phone/Fax

Practice location:
  • Phone: 575-779-3391
  • Fax:
Mailing address:
  • Phone: 575-779-3391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06602
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: