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General NPI Number Information
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NPI Number | 1912962739
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Entity Type | Individual
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Provider Name | VIRGINIA MARIE HOLBROOK LISW
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Gender | Female
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Dates
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Enumeration Date | 04/18/2006
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Last Update Date | 08/01/2011
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Provider Practice Location Address
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Address Line | 1960 N DATE ST
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City | TRUTH OR CONSEQUENCES
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State | NM
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Zip | 87901-3701
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Country | US
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Telephone | 575-894-7662
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Fax | 575-894-7930
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Provider Business Mailing Address
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Address Line | PO BOX 370
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City | HATCH
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State | NM
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Zip | 87937
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Country | US
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Telephone | 575-267-3280
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Fax | 575-267-1747
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | M4321
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | I-06764
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | I-06764
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License Number State | NM
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