Healthcare Provider Details

I. General information

NPI: 1043776669
Provider Name (Legal Business Name): LISA WILLOUGHBY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2019
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MARSHALL ST
TRUTH OR CONSEQUENCES NM
87901-6600
US

IV. Provider business mailing address

900 MARSHALL ST
TRUTH OR CONSEQUENCES NM
87901-6600
US

V. Phone/Fax

Practice location:
  • Phone: 575-740-5096
  • Fax:
Mailing address:
  • Phone: 575-740-5096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2025-1008
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: