Healthcare Provider Details

I. General information

NPI: 1851799563
Provider Name (Legal Business Name): LISA ANDERSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2014
Last Update Date: 06/14/2023
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DRIVE SE
ALBUQUERQUE NM
87108
US

IV. Provider business mailing address

1380 RIO RANCHO BLVD SE # 441
RIO RANCHO NM
87124-1006
US

V. Phone/Fax

Practice location:
  • Phone: 505-620-9686
  • Fax:
Mailing address:
  • Phone: 505-620-9686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number254886
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149022501
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-08302
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: