Healthcare Provider Details

I. General information

NPI: 1669724043
Provider Name (Legal Business Name): LISA KADEL BARTLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2012
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 S SAINT FRANCIS DR #2
SANTA FE NM
87505-3082
US

IV. Provider business mailing address

1721C CAMINO DOS ANTONIOS # 15
SANTA FE NM
87507-3322
US

V. Phone/Fax

Practice location:
  • Phone: 505-231-5152
  • Fax:
Mailing address:
  • Phone: 505-231-5152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0165761
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: