Basic Information
| Provider Information | |||||||||
| NPI: | 1942351739 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLOW | ||||||||
| FirstName: | MIKKI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | L.M.S.W | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5608 ZUNI RD SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871082926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052626523 | ||||||||
| FaxNumber: | 5052657045 | ||||||||
| Practice Location | |||||||||
| Address1: | 5608 ZUNI RD SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871082926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052626523 | ||||||||
| FaxNumber: | 5052657045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | X05719 | NM | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | NM | MEDICAID |