Healthcare Provider Details

I. General information

NPI: 1649577131
Provider Name (Legal Business Name): LISA LUTTBEG MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 HUNTER ST
ESPANOLA NM
87532-2655
US

IV. Provider business mailing address

404 HUNTER ST
ESPANOLA NM
87532-2655
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-4123
  • Fax: 505-753-6947
Mailing address:
  • Phone: 505-753-4123
  • Fax: 505-753-6947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberX07187
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: