Healthcare Provider Details

I. General information

NPI: 1912913674
Provider Name (Legal Business Name): LISA PENCE L.I.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1444 S SAINT FRANCIS DR # C
SANTA FE NM
87505-4038
US

IV. Provider business mailing address

PO BOX 22960
SANTA FE NM
87502-2960
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-8228
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-2538
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: