MEDICARE: ELIZABETH JEAN WOLFF 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-05918	NM

General Provider Information

NPI Number	:	1487889077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH JEAN WOLFF LISW

Provider Business Mailing Address
First Line	:	2815 RHODE ISLAND ST NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-3703
Country	:	US
Telephone Number	:	505-977-8834
Fax Number	:	505-797-0310

Provider Business Practice Location Address
First Line	:	2626 CENTRAL AVE SW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87104-1616
Country	:	US
Telephone Number	:	505-977-8834
Fax Number	:	505-797-0310

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

Provider Enumeration Date	:	05/26/2009
Last Update Date	:	05/26/2009

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