Healthcare Provider Details

I. General information

NPI: 1255457339
Provider Name (Legal Business Name): ELIZABETH SUSAN SPEAKER LCPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8417 WASHINGTON PL NE STE B
ALBUQUERQUE NM
87113-1720
US

IV. Provider business mailing address

8417 WASHINGTON PL NE STE B
ALBUQUERQUE NM
87113-1720
US

V. Phone/Fax

Practice location:
  • Phone: 505-507-4408
  • Fax:
Mailing address:
  • Phone: 505-507-4408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0102551
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: