Healthcare Provider Details

I. General information

NPI: 1093502890
Provider Name (Legal Business Name): TISHAWNA THOMPSON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 MOON ST NE
ALBUQUERQUE NM
87112-3935
US

IV. Provider business mailing address

1709 MOON ST NE
ALBUQUERQUE NM
87112-3935
US

V. Phone/Fax

Practice location:
  • Phone: 505-271-4957
  • Fax: 505-271-4957
Mailing address:
  • Phone: 505-607-3507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB20240755
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberCTB20250805
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: