MEDICARE: MRS. PHYLLIS M SKOY 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-04570	NM

General Provider Information

NPI Number	:	1346312667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PHYLLIS M SKOY LISW

Provider Business Mailing Address
First Line	:	3901 GEORGIA ST NE
Second Line	:	BLDG. A SUITE 4
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-1359
Country	:	US
Telephone Number	:	505-480-8225
Fax Number	:

Provider Business Practice Location Address
First Line	:	3901 GEORGIA ST NE
Second Line	:	BLDG. A SUITE 4
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-1359
Country	:	US
Telephone Number	:	505-480-8225
Fax Number	:

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

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	10/03/2012

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