MEDICARE: MS. TWILA BECENTI-FUNDARK 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-4224	NM

General Provider Information

NPI Number	:	1710136726
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TWILA BECENTI-FUNDARK LISW

Provider Business Mailing Address
First Line	:	355 S MILLER AVE
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87401-6463
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	355 S. MILLER
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87401-5617
Country	:	US
Telephone Number	:	505-566-0515
Fax Number	:

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

Provider Enumeration Date	:	09/15/2008
Last Update Date	:	10/14/2011

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Directions to “ MS. TWILA BECENTI-FUNDARK LISW” Practice Location

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