Healthcare Provider Details

I. General information

NPI: 1689861916
Provider Name (Legal Business Name): GEORGINA MESIBOV LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GEORGINA WILLIAMS LPCC

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 05/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 CENTRAL PARK SQUARE
LAS ALAMOS NM
87544
US

IV. Provider business mailing address

4715 QUEMAZON
LOS ALAMOS NM
87544
US

V. Phone/Fax

Practice location:
  • Phone: 505-695-0233
  • Fax: 505-661-9637
Mailing address:
  • Phone: 505-695-0233
  • Fax: 505-661-9637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number006109
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: