Provider Demographics
NPI:1306163316
Name:HILL, MICHAEL WAIDNER (LISW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WAIDNER
Last Name:HILL
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 158
Mailing Address - Street 2:620 N CORONADO AVE
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0238
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-753-5815
Practice Address - Street 1:2010 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3600
Practice Address - Country:US
Practice Address - Phone:505-753-7395
Practice Address - Fax:505-753-8373
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-00881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM91585Medicaid
NMNM100915OtherMEDICARE PTAN