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General NPI Number Information
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NPI Number | 1639595291
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Entity Type | Organization
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Legal Business Name | MELISSA HAGSTRUM LISW PHD
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Dates
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Enumeration Date | 03/06/2014
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Last Update Date | 03/06/2014
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Provider Practice Location Address
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Address Line | 901 W SAN MATEO RD D4
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City | SANTA FE
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State | NM
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Zip | 87505-3981
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Country | US
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Telephone | 505-660-0403
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Fax |
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Provider Business Mailing Address
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Address Line | 6 FRASCO RD
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City | SANTA FE
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State | NM
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Zip | 87508-8842
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Country | US
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Telephone | 505-660-0403
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MELISSA B. HAGSTRUM
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Credential | LISW, PHD
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Telephone | 505-660-0403
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | I-08107
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License Number State | NM
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