Healthcare Provider Details

I. General information

NPI: 1467692681
Provider Name (Legal Business Name): MAXINE A NAKAI LISW, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2009
Last Update Date: 02/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 ROTTEN TREE RD
TAOS NM
87571
US

IV. Provider business mailing address

PO BOX 1846 230 ROTTEN TREE RD
TAOS NM
87571-1846
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-7824
  • Fax: 575-758-3346
Mailing address:
  • Phone: 575-758-7824
  • Fax: 575-758-3346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1856
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-2895
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: