Healthcare Provider Details

I. General information

NPI: 1912962739
Provider Name (Legal Business Name): VIRGINIA MARIE HOLBROOK LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIRGINIA MARIE OETTINGER MSW

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 N DATE ST
TRUTH OR CONSEQUENCES NM
87901-3701
US

IV. Provider business mailing address

PO BOX 370
HATCH NM
87937
US

V. Phone/Fax

Practice location:
  • Phone: 575-894-7662
  • Fax: 575-894-7930
Mailing address:
  • Phone: 575-267-3280
  • Fax: 575-267-1747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM4321
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI-06764
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06764
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: