Provider Demographics
NPI:1265870869
Name:LAROSA-CORLISS, MADELYN FRANCES (LISW)
Entity type:Individual
Prefix:
First Name:MADELYN
Middle Name:FRANCES
Last Name:LAROSA-CORLISS
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 1:1707 N VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-4625
Mailing Address - Country:US
Mailing Address - Phone:575-313-2730
Mailing Address - Fax:
Practice Address - Street 1:1707 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-4625
Practice Address - Country:US
Practice Address - Phone:575-313-2730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-080501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical