Healthcare Provider Details

I. General information

NPI: 1740443738
Provider Name (Legal Business Name): SUSAN TANYA LEHERISSEY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 UPPER LLANO RD
LLANO NM
87543
US

IV. Provider business mailing address

PO BOX 9
LLANO NM
87543-0009
US

V. Phone/Fax

Practice location:
  • Phone: 575-587-2063
  • Fax:
Mailing address:
  • Phone: 575-587-2063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1790
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: