MEDICARE: MS. SUSANA LEE SINCLAIR 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-0855	NM

General Provider Information

NPI Number	:	1043381247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSANA LEE SINCLAIR LISW

Provider Business Mailing Address
First Line	:	404 SAN MATEO BLVD NE
Second Line	:	SUITE 45
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87108-5547
Country	:	US
Telephone Number	:	505-331-7084
Fax Number	:

Provider Business Practice Location Address
First Line	:	404 SAN MATEO BLVD NE
Second Line	:	SUITE 45
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87108-5547
Country	:	US
Telephone Number	:	505-331-7084
Fax Number	:

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

Provider Enumeration Date	:	11/11/2006
Last Update Date	:	07/08/2007

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