Healthcare Provider Details

I. General information

NPI: 1588065452
Provider Name (Legal Business Name): LORISSA MARIE GARCIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2014
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2543 WYOMING BLVD NE
ALBUQUERQUE NM
87112-1037
US

IV. Provider business mailing address

3420 PICKARD AVE NE
ALBUQUERQUE NM
87110-2226
US

V. Phone/Fax

Practice location:
  • Phone: 505-721-0854
  • Fax:
Mailing address:
  • Phone: 505-721-0847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0184481
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0177341
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: