Healthcare Provider Details

I. General information

NPI: 1003061946
Provider Name (Legal Business Name): SHELLEY SUE STISSER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELLEY SUE STISSER-MCCRAIGH LPC

II. Dates (important events)

Enumeration Date: 11/19/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8205 SPAIN RD NE STE 106
ALBUQUERQUE NM
87109-3155
US

IV. Provider business mailing address

9342 S 182ND LN
GOODYEAR AZ
85338-5254
US

V. Phone/Fax

Practice location:
  • Phone: 505-856-0300
  • Fax: 505-856-7946
Mailing address:
  • Phone: 623-810-7266
  • Fax: 623-321-1378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC12877
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0155941
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: