Healthcare Provider Details

I. General information

NPI: 1093300196
Provider Name (Legal Business Name): ANTHONY LISIGNOLI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2021
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 BERTHA RD STE B
TAOS NM
87571-7148
US

IV. Provider business mailing address

3322 SANTA CLARA AVE SE
ALBUQUERQUE NM
87106-1531
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-4297
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: