Healthcare Provider Details

I. General information

NPI: 1033419577
Provider Name (Legal Business Name): LISA WHITNEY SWANSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA GOMME

II. Dates (important events)

Enumeration Date: 11/01/2010
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2537 ASPEN AVE NW
ALBUQUERQUE NM
87104-1919
US

IV. Provider business mailing address

3301R COORS BLVD NW # 265
ALBUQUERQUE NM
87120-1229
US

V. Phone/Fax

Practice location:
  • Phone: 505-206-5460
  • Fax:
Mailing address:
  • Phone: 505-459-9301
  • Fax: 505-884-1081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0193841
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0134911
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH0193841
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: