=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275201725
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY R. FAWVER LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2021
-----------------------------------------------------
Last Update Date | 01/14/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5345 WYOMING BLVD NE STE 107
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-3193
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-238-3345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9577 OSUNA RD NE STE B
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87111-2286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-238-3345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | M-11646
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------