=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073010658
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA BUSICH LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2018
-----------------------------------------------------
Last Update Date | 10/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6501 4TH ST NW
-----------------------------------------------------
City | LOS RANCHOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107-5800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-433-7561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11500 ROSEMONT AVE NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87112-5643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-573-1113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | SWB-2022-0969
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------