Provider Demographics
NPI:1710041264
Name:FOX, NATHAN (LISW)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:FOX
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 9TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3026
Mailing Address - Country:US
Mailing Address - Phone:505-266-0388
Mailing Address - Fax:505-268-1063
Practice Address - Street 1:3212 MONTE VISTA BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2120
Practice Address - Country:US
Practice Address - Phone:505-203-7676
Practice Address - Fax:505-243-9261
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-055881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM33031738Medicaid