Provider Demographics
NPI:1609181429
Name:GRANITO-TIBBETTS, MICHAELA (LMSW)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:GRANITO-TIBBETTS
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 1:7 ESQUINA RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-9172
Mailing Address - Country:US
Mailing Address - Phone:505-466-4944
Mailing Address - Fax:505-467-2648
Practice Address - Street 1:1300 CAMINO SIERRA VIS
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1007
Practice Address - Country:US
Practice Address - Phone:505-466-4944
Practice Address - Fax:505-467-2648
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-057781041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME7606Medicaid