Healthcare Provider Details

I. General information

NPI: 1497058184
Provider Name (Legal Business Name): LISA ANN CELOSSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2010
Last Update Date: 12/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 ASPEN DR STE 302A
SANTA FE NM
87505-5588
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 TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0091031
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMFC38644
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0104011
License Number StateNM

VIII. Authorized Official

Name: LISA A CELOSSE
Title or Position: LPCC. LMFT
Credential: LPCC, LMFT
Phone: 505-720-9167