Healthcare Provider Details

I. General information

NPI: 1710387105
Provider Name (Legal Business Name): LIZA C MERMELSTEIN PHD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9426 INDIAN SCHOOL RD NE SUITE 1
ALBUQUERQUE NM
87112-2886
US

IV. Provider business mailing address

9426 INDIAN SCHOOL RD NE SUITE 1
ALBUQUERQUE NM
87112-2886
US

V. Phone/Fax

Practice location:
  • Phone: 505-345-6100
  • Fax: 505-345-4531
Mailing address:
  • Phone: 505-345-6100
  • Fax: 505-345-4531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1347
License Number StateNM

VIII. Authorized Official

Name: LIZA CHYTILO MERMELSTEIN
Title or Position: MANAGING MEMBER
Credential: PHD
Phone: 607-768-9640