Healthcare Provider Details

I. General information

NPI: 1912224999
Provider Name (Legal Business Name): ROSE MARIE CODOVA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 ROTTEN TREE ROAD
TAOS NM
87571-1846
US

IV. Provider business mailing address

PO BOX 1846
TAOS NM
87571-1846
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-4224
  • Fax: 575-751-5219
Mailing address:
  • Phone: 575-758-4224
  • Fax: 575-751-5219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-3352
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: