Healthcare Provider Details

I. General information

NPI: 1437965415
Provider Name (Legal Business Name): LISTO HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 GIBSON BLVD SE
ALBUQUERQUE NM
87108-5566
US

IV. Provider business mailing address

5400 GIBSON BLVD SE STE 4
ALBUQUERQUE NM
87108-5181
US

V. Phone/Fax

Practice location:
  • Phone: 505-418-1777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ALEX MCCABE
Title or Position: CEO
Credential:
Phone: 505-418-1777