Healthcare Provider Details

I. General information

NPI: 1780629063
Provider Name (Legal Business Name): JOAN BRUMAGE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 MICHIGAN AVE
ALAMOGORDO NM
88310-6725
US

IV. Provider business mailing address

PO BOX 1330
NORMAN OK
73070-1330
US

V. Phone/Fax

Practice location:
  • Phone: 575-921-1616
  • Fax: 575-434-3253
Mailing address:
  • Phone: 405-307-6630
  • Fax: 405-307-6660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI05349
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: