Healthcare Provider Details

I. General information

NPI: 1285723395
Provider Name (Legal Business Name): LISA CELOSSE LPCC, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 08/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 GALISTEO, N-10D
SANTA FE NM
87505
US

IV. Provider business mailing address

PO BOX 250
CHIMAYO NM
87522-0250
US

V. Phone/Fax

Practice location:
  • Phone: 505-720-9167
  • Fax:
Mailing address:
  • Phone: 505-720-9167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0091031
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: