Healthcare Provider Details

I. General information

NPI: 1780938415
Provider Name (Legal Business Name): LISA MARIE SIEBEN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2012
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 MOUNTAIN RD NE 200 B
ALBUQUERQUE NM
87110-7818
US

IV. Provider business mailing address

637 CHARLESTON ST NE
ALBUQUERQUE NM
87108-2109
US

V. Phone/Fax

Practice location:
  • Phone: 505-380-6500
  • Fax:
Mailing address:
  • Phone: 505-321-7579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0149561
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: