Provider Demographics
NPI:1225456700
Name:SELF, LOUISE (LM, CPM)
Entity Type:Individual
Prefix:
First Name:LOUISE
Middle Name:
Last Name:SELF
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4916 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-3949
Mailing Address - Country:US
Mailing Address - Phone:505-450-2222
Mailing Address - Fax:877-500-7949
Practice Address - Street 1:4916 4TH ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-3949
Practice Address - Country:US
Practice Address - Phone:505-450-2222
Practice Address - Fax:877-500-7949
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1412R176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54937582Medicaid