Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | M-11722 | NM |
NPI | 1003587551 |
---|---|
Provider Name | Kyle Rouckus |
First Address | Albuquerque, NM 87106-1323 |
Second Address | Albuquerque, NM 87106-1323 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/09/2021 |
Last Update Date | 24/09/2021 |