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General NPI Number Information
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NPI Number | 1194814228
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Entity Type | Individual
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Provider Name | SUSAN S. BREAZEALE LISW
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Gender | Female
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 01/16/2020
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Provider Practice Location Address
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Address Line | 36 NIEMAN RD
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City | ARROYO HONDO
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State | NM
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Zip | 87513
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Country | US
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Telephone | 575-613-0430
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1483
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City | EL PRADO
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State | NM
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Zip | 87529-1483
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Country | US
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Telephone | 575-613-0430
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | I-04744
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | C-04744
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License Number State | NM
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