{
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"FirstLineMailingAddress": "1096 MECHEM DR",
"SecondLineMailingAddress": "SUITE 202",
"MailingAddressCityName": "RUIDOSO",
"MailingAddressStateName": "NM",
"MailingAddressPostalCode": "88345-7067",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "575-808-8380",
"MailingAddressFaxNumber": "575-808-8380",
"FirstLinePracticeLocationAddress": "1096 MECHEM DR",
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"PracticeLocationAddressTelephoneNumber": "575-808-8380",
"PracticeLocationAddressFaxNumber": "575-808-8380",
"EnumerationDate": "11/30/2011",
"LastUpdateDate": "11/30/2011",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
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"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "OVRICK",
"AuthorizedOfficialFirstName": "MARK",
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"AuthorizedOfficialTitle": "LICENSED INDEPENDENT SOCIAL WORKER",
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"AuthorizedOfficialCredential": "LISW",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Clinical Social Worker",
"LicenseNumber": "I-05300",
"LicenseNumberStateCode": "NM",
"PrimaryTaxonomySwitch": "Y"
}
},
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"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}