MEDICARE: VICKIE LYNNE WETHINGTON LMSW

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	104100000X	Social Worker	B-04623	NM

General Provider Information

NPI Number	:	1790092054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICKIE LYNNE WETHINGTON LMSW

Provider Business Mailing Address
First Line	:	851 ANDREA DR
Second Line	:	SUITE 4, BUILDING E
City	:	FARMINGTON
State	:	NM
Zip	:	87401-6726
Country	:	US
Telephone Number	:	505-324-5855
Fax Number	:	505-324-5896

Provider Business Practice Location Address
First Line	:	851 ANDREA DR
Second Line	:	SUITE 4, BUIDLING E
City	:	FARMINGTON
State	:	NM
Zip	:	87401-6726
Country	:	US
Telephone Number	:	505-324-5855
Fax Number	:	505-324-5896

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

Provider Enumeration Date	:	09/08/2010
Last Update Date	:	10/04/2011

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