Healthcare Provider Details

I. General information

NPI: 1326077272
Provider Name (Legal Business Name): LETICIA MARQUEZ LISAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 10/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N. HOPI STREET
SPRINGERVILLE AZ
85938
US

IV. Provider business mailing address

50 N. HOPI STREET
SPRINGERVILLE AZ
85938
US

V. Phone/Fax

Practice location:
  • Phone: 928-333-2683
  • Fax: 928-333-5595
Mailing address:
  • Phone: 928-333-2683
  • Fax: 928-333-5595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-10373
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: