Healthcare Provider Details

I. General information

NPI: 1366749004
Provider Name (Legal Business Name): MS. LISA MARDEL SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2011
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 CENTRAL AVE SW
ALBUQUERQUE NM
87102-2947
US

IV. Provider business mailing address

301 SAN ANDRES AVE NW
ALBUQUERQUE NM
87107-3950
US

V. Phone/Fax

Practice location:
  • Phone: 505-639-5916
  • Fax:
Mailing address:
  • Phone: 505-639-5916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number17178
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2023-0939
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: