Healthcare Provider Details

I. General information

NPI: 1972933844
Provider Name (Legal Business Name): TISA BERNALLY-RUSSELL BSW, LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2013
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W BROADWAY SUITE D
FARMINGTON NM
87401-6419
US

IV. Provider business mailing address

PO BOX 3239 101 W. BROADWAY, SUITE D
FARMINGTON NM
87499-3239
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-4796
  • Fax:
Mailing address:
  • Phone: 505-327-4796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0160331
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: