Provider Demographics
NPI:1376086298
Name:CYNTHIA SONTAG, LCSW
Entity Type:Organization
Organization Name:CYNTHIA SONTAG, LCSW
Other - Org Name:THE SOURCE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SONTAG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:505-263-1001
Mailing Address - Street 1:310 13TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-1834
Mailing Address - Country:US
Mailing Address - Phone:505-263-1001
Mailing Address - Fax:505-234-1019
Practice Address - Street 1:310 13TH ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1834
Practice Address - Country:US
Practice Address - Phone:505-263-1001
Practice Address - Fax:505-234-1019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-25
Last Update Date:2016-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-19911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM528708OtherMEDICARE PTAN