Provider Demographics
NPI:1619475944
Name:WASSERMAN, ROBERT MURRAY (LMSW)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MURRAY
Last Name:WASSERMAN
Suffix:
Gender:M
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:P.O. BOX 1634
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81302
Mailing Address - Country:US
Mailing Address - Phone:970-729-1178
Mailing Address - Fax:
Practice Address - Street 1:203 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-4210
Practice Address - Country:US
Practice Address - Phone:970-729-1178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NMM-10625104100000X
NMX-11676104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1619475944OtherBCBS