Healthcare Provider Details

I. General information

NPI: 1851786446
Provider Name (Legal Business Name): NICHOLAS BOEDER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 12/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 GUSDORF ROAD BUILDING E
TAOS NM
87571
US

IV. Provider business mailing address

PO BOX 437
EL PRADO NM
87529
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-0670
  • Fax:
Mailing address:
  • Phone: 575-770-0436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-08893
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: