Healthcare Provider Details

I. General information

NPI: 1306175518
Provider Name (Legal Business Name): TISHA MARIE SJOSTRAND LMHC, LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2009
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2126 PAM Y EUTILIA
SANTA FE NM
87507-3257
US

IV. Provider business mailing address

2126 PAM Y EUTILIA
SANTA FE NM
87507-3257
US

V. Phone/Fax

Practice location:
  • Phone: 505-699-6751
  • Fax:
Mailing address:
  • Phone: 505-699-6751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0104951
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: