Healthcare Provider Details

I. General information

NPI: 1770853228
Provider Name (Legal Business Name): ANNALISA GOLOWACZ MA, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2011
Last Update Date: 12/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 LOS LENTES, SE
LOS LUNAS NM
87031
US

IV. Provider business mailing address

PO BOX 3301
LOS LUNAS NM
87031-3301
US

V. Phone/Fax

Practice location:
  • Phone: 505-807-1534
  • Fax:
Mailing address:
  • Phone: 505-807-1534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0122501
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: