Basic Information
| Provider Information | |||||||||
| NPI: | 1457391492 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | BHANU | ||||||||
| MiddleName: | JOY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4308 CARLISLE BLVD NE | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871074856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058372100 | ||||||||
| FaxNumber: | 5058887943 | ||||||||
| Practice Location | |||||||||
| Address1: | 4308 CARLISLE BLVD NE | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871074856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058372100 | ||||||||
| FaxNumber: | 5058887943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 05/25/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I5529 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 201047515 | 01 | NM | PRESBYTERIAN HEALTH PLAN | OTHER | 02158728 | 05 | NM | MEDICAID | VNM0130 | 01 | NM | VALVE OPTIONS | OTHER | NM101457 | 01 | NM | VALVE OPTIONS | OTHER |