=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649652215
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATRINA ANNE ENGSTROM LSCW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2015
-----------------------------------------------------
Last Update Date | 07/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1909 CUBA AVE STE 5
-----------------------------------------------------
City | ALAMOGORDO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88310-5646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-489-4916
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 2ND AVE N STE 200D
-----------------------------------------------------
City | GREAT FALLS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59401-3243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-430-4919
-----------------------------------------------------
Fax | 855-679-5989
-----------------------------------------------------
=====================================================
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 | C-10569
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------