Healthcare Provider Details

I. General information

NPI: 1174658819
Provider Name (Legal Business Name): LISA ECKELKAMP MS, CCC-SLP, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 04/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 MAES RD B
CORRALES NM
87048
US

IV. Provider business mailing address

PO BOX 2674
CORRALES NM
87048
US

V. Phone/Fax

Practice location:
  • Phone: 505-249-8714
  • Fax:
Mailing address:
  • Phone: 505-249-8714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3167
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number11623536
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: