MEDICARE: SANDRA M FORTIER LISW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	I-06875	NM

General Provider Information

NPI Number	:	1023199338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA M FORTIER LISW

Provider Business Mailing Address
First Line	:	4 CAMINO MESTENO
Second Line	:
City	:	PLACITAS
State	:	NM
Zip	:	87043-8623
Country	:	US
Telephone Number	:	505-771-9279
Fax Number	:

Provider Business Practice Location Address
First Line	:	4351 JAGER DR NE
Second Line	:	SUITE C
City	:	RIO RANCHO
State	:	NM
Zip	:	87144-7523
Country	:	US
Telephone Number	:	505-410-5686
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	12/14/2009

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