Provider Demographics
NPI:1043776669
Name:WILLOUGHBY, LISA (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 N DATE ST
Mailing Address - Street 2:
Mailing Address - City:T OR C
Mailing Address - State:NM
Mailing Address - Zip Code:87901-2810
Mailing Address - Country:US
Mailing Address - Phone:575-894-8382
Mailing Address - Fax:
Practice Address - Street 1:180 N DATE ST
Practice Address - Street 2:
Practice Address - City:T OR C
Practice Address - State:NM
Practice Address - Zip Code:87901-2810
Practice Address - Country:US
Practice Address - Phone:575-894-8382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3904271041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool