Healthcare Provider Details

I. General information

NPI: 1639254154
Provider Name (Legal Business Name): LISA DIAN WOOLDRIDGE LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA DIAN WARE

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 SAINT MICHAELS DR STE 2
SANTA FE NM
87505-7655
US

IV. Provider business mailing address

411 SAINT MICHAELS DR STE 2
SANTA FE NM
87505-7655
US

V. Phone/Fax

Practice location:
  • Phone: 505-690-8322
  • Fax:
Mailing address:
  • Phone: 505-690-8322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0065012
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: