Healthcare Provider Details

I. General information

NPI: 1649834771
Provider Name (Legal Business Name): AMY DONDANVILLE LCSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 PASEO DEL PUEBLO NORTE
TAOS NM
87571-5908
US

IV. Provider business mailing address

PO BOX 537
TAOS NM
87571-0537
US

V. Phone/Fax

Practice location:
  • Phone: 575-224-2710
  • Fax:
Mailing address:
  • Phone: 575-224-2710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: APRIL BANCROFT
Title or Position: DIR OF OPERATIONS
Credential: CREDENTIALING
Phone: 505-384-7352