Healthcare Provider Details

I. General information

NPI: 1386030963
Provider Name (Legal Business Name): LISA MORAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4477 IRVING BLVD NW STE B
ALBUQUERQUE NM
87114-5529
US

IV. Provider business mailing address

4477 IRVING BLVD NW STE B
ALBUQUERQUE NM
87114-5529
US

V. Phone/Fax

Practice location:
  • Phone: 505-221-6214
  • Fax: 505-298-4737
Mailing address:
  • Phone: 505-221-6214
  • Fax: 505-298-4737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY-2024-0071
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number26724
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: