Healthcare Provider Details

I. General information

NPI: 1437481207
Provider Name (Legal Business Name): PATTI H MACOMBER LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2010
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 CENTRAL AVE SE SUITE 300
ALBUQUERQUE NM
87102-3460
US

IV. Provider business mailing address

202 CENTRAL AVE SE SUITE 300
ALBUQUERQUE NM
87102-3460
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-1125
  • Fax:
Mailing address:
  • Phone: 505-268-1125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI-05166
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: