MEDICARE: GEORGE WILLIAM DURAN 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	1041S0200X	School Social Worker	I3577	NM
2	1041C0700X	Clinical Social Worker	I-3577	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225165566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGE WILLIAM DURAN LISW

Provider Business Mailing Address
First Line	:	747 KELLI CIR
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88007-5219
Country	:	US
Telephone Number	:	575-635-8150
Fax Number	:

Provider Business Practice Location Address
First Line	:	747 KELLI CIR
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88007-5219
Country	:	US
Telephone Number	:	575-635-8150
Fax Number	:

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

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	02/02/2015

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