Healthcare Provider Details

I. General information

NPI: 1992825541
Provider Name (Legal Business Name): KELLY EARLEY LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N MESA RD
BELEN NM
87002-8528
US

IV. Provider business mailing address

PO BOX 518
LOS LUNAS NM
87031-0518
US

V. Phone/Fax

Practice location:
  • Phone: 505-864-9113
  • Fax: 505-861-3681
Mailing address:
  • Phone: 505-865-3350
  • Fax: 505-865-4739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI-06404
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: