Provider Demographics
NPI:1740214485
Name:STEVENSON, LAURIE ANN (LISW)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:ANN
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4135 MONTGOMERY BLVD NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-6756
Mailing Address - Country:US
Mailing Address - Phone:505-610-0171
Mailing Address - Fax:505-883-9088
Practice Address - Street 1:4135 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-6756
Practice Address - Country:US
Practice Address - Phone:505-610-0171
Practice Address - Fax:505-883-9088
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-14671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM95241Medicaid