MEDICARE: TATIA O LIPE LCSW, ACCTS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	0122711	NM
2	1041C0700X	Clinical Social Worker	I-07992	NM
3	1041C0700X	Clinical Social Worker	C-07992	NM

General Provider Information

NPI Number	:	1205080983
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TATIA O LIPE LCSW, ACCTS

Provider Business Mailing Address
First Line	:	6424 AVENIDA SEVILLE NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87114-3765
Country	:	US
Telephone Number	:	575-317-8717
Fax Number	:	575-208-0325

Provider Business Practice Location Address
First Line	:	4141 MONTGOMERY BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-6741
Country	:	US
Telephone Number	:	505-560-2804
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2008
Last Update Date	:	09/10/2022

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