Provider Demographics
NPI:1851422679
Name:MAIOLO-PUTNAM, VICKI (LISW)
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:
Last Name:MAIOLO-PUTNAM
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 1:1898 ESPLENDOR ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5605
Mailing Address - Country:US
Mailing Address - Phone:505-467-1508
Mailing Address - Fax:
Practice Address - Street 1:1300 CAMINO SIERRA VIS
Practice Address - Street 2:129
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1007
Practice Address - Country:US
Practice Address - Phone:505-467-2504
Practice Address - Fax:505-467-2646
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI26721041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMJ4335Medicaid