Provider Demographics
NPI:1992866842
Name:BALTO, BRUCE (LISW, DCSW)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:BALTO
Suffix:
Gender:M
Credentials:LISW, DCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 67691
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87193-7691
Mailing Address - Country:US
Mailing Address - Phone:505-227-3052
Mailing Address - Fax:505-792-4057
Practice Address - Street 1:3417 CARLISLE BLVD. NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1648
Practice Address - Country:US
Practice Address - Phone:505-227-3052
Practice Address - Fax:505-792-4057
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-063001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM17502331Medicaid
339800702Medicare PIN