Provider Demographics
NPI:1093049785
Name:HART, JODIE L (LMSW)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:L
Last Name:HART
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3326 LINDA VISTA AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-1514
Mailing Address - Country:US
Mailing Address - Phone:505-450-8007
Mailing Address - Fax:505-268-8949
Practice Address - Street 1:608 BLEDSOE RD NW
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-6219
Practice Address - Country:US
Practice Address - Phone:505-450-8007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-28
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-060611041C0700X
NMX-068621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical