MEDICARE: LISA DIAN WOOLDRIDGE LPCC

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	101YP2500X	Professional Counselor	0065012	NM

General Provider Information

NPI Number	:	1639254154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA DIAN WOOLDRIDGE LPCC

Provider Business Mailing Address
First Line	:	411 SAINT MICHAELS DR STE 2
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-7655
Country	:	US
Telephone Number	:	505-690-8322
Fax Number	:

Provider Business Practice Location Address
First Line	:	411 SAINT MICHAELS DR STE 2
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-7655
Country	:	US
Telephone Number	:	505-690-8322
Fax Number	:

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

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	03/17/2018

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