Healthcare Provider Details

I. General information

NPI: 1033865803
Provider Name (Legal Business Name): LISA A. MOORE MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 07/26/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 OLD PECOS TRL STE A
SANTA FE NM
87505-4778
US

IV. Provider business mailing address

5426 STILL BROOKE AVE NW
ALBUQUERQUE NM
87120-3384
US

V. Phone/Fax

Practice location:
  • Phone: 651-313-8080
  • Fax:
Mailing address:
  • Phone: 620-778-2269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2022-0470
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: