MEDICARE: STREETWISE INC

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	251S00000X	Community/Behavioral Health Agency		NM
2	251S00000X	Community/Behavioral Health Agency	600153	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	:	1649315102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STREETWISE INC

Provider Business Mailing Address
First Line	:	4312 CARLISLE BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-4811
Country	:	US
Telephone Number	:	505-323-3785
Fax Number	:	505-323-3850

Provider Business Practice Location Address
First Line	:	4312 CARLISLE BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-4811
Country	:	US
Telephone Number	:	505-323-3785
Fax Number	:	505-323-3850

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	PHYLLIS MARQUEZ
Credential	:
Telephone Number	:	505-323-3785

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/21/2022

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Directions to “STREETWISE INC ” Practice Location

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