Individual
MYSTI JO CHURCH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LMSW
Contact information
Practice address
914 N CANAL ST, CARLSBAD, NM 88220-5110
(575) 885-4836
(505) 443-8319
Mailing address
914 N CANAL ST, CARLSBAD, NM 88220-5110
(575) 885-4836
(505) 443-8319
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
SWB-2023-0090
NM
172V00000X
Community Health Worker
—
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02486417000
—
NM
Enumeration date
04/13/2021
Last updated
10/04/2023
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