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General NPI Number Information
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NPI Number | 1730312489
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Entity Type | Individual
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Provider Name | MARY JO H SHORTES LISW
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Gender | Female
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Dates
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Enumeration Date | 08/28/2009
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Last Update Date | 01/24/2012
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Provider Practice Location Address
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Address Line | #1 FOSTER ROAD
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City | RESERVE
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State | NM
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Zip | 87830
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Country | US
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Telephone | 575-533-6456
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Fax | 575-533-6767
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Provider Business Mailing Address
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Address Line | PO BOX 710
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City | RESERVE
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State | NM
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Zip | 87830-0710
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Country | US
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Telephone | 575-533-6456
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Fax | 575-533-6767
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | I-06997
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License Number State | NM
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