Provider Demographics
NPI:1962917096
Name:KLEBANOFF-TAYLOR, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KLEBANOFF-TAYLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 HANNETT AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5014
Mailing Address - Country:US
Mailing Address - Phone:505-948-4636
Mailing Address - Fax:
Practice Address - Street 1:4100 BARBARA LOOP SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1000
Practice Address - Country:US
Practice Address - Phone:505-313-7057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-111621041C0700X
NMM-096691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical