=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992866842
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRUCE BALTO LISW, DCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2006
-----------------------------------------------------
Last Update Date | 04/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3417 CARLISLE BLVD. NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87110-1648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-227-3052
-----------------------------------------------------
Fax | 505-792-4057
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 67691
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87193-7691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-227-3052
-----------------------------------------------------
Fax | 505-792-4057
-----------------------------------------------------
=====================================================
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 | I-06300
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------