Basic Information
Provider Information | |||||||||
NPI: | 1922095314 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TSOSIE | ||||||||
FirstName: | PAULINE | ||||||||
MiddleName: | NMN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TSOSIE | ||||||||
OtherFirstName: | PAULINE | ||||||||
OtherMiddleName: | T | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MSW | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 160 | ||||||||
Address2: |   | ||||||||
City: | SHIPROCK | ||||||||
State: | NM | ||||||||
PostalCode: | 874200160 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5053686401 | ||||||||
FaxNumber: | 5053686431 | ||||||||
Practice Location | |||||||||
Address1: | US HWY 491 N | ||||||||
Address2: |   | ||||||||
City: | SHIPROCK | ||||||||
State: | NM | ||||||||
PostalCode: | 87420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5053686401 | ||||||||
FaxNumber: | 5053686431 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/30/2005 | ||||||||
LastUpdateDate: | 06/03/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | M2233 | NM | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 07455020 | 05 | NM |   | MEDICAID | 77903528 | 05 | CO |   | MEDICAID |