1710171137 NPI number — CAROLYN REED GRIFFIN LISW

Table of content: CAROLYN REED GRIFFIN LISW (NPI 1710171137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710171137 NPI number — CAROLYN REED GRIFFIN LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIFFIN
Provider First Name:
CAROLYN
Provider Middle Name:
REED
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710171137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4601 BREECE RD SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87105-6405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-873-1270
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8300 CONSTITUTION NE
Provider Second Line Business Practice Location Address:
CONSULT LIASION SERVICE
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-291-2134
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  I-0455 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 21700567 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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