Provider Demographics
NPI:1073706768
Name:CLUGSTON, LISA (LPCC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CLUGSTON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 GRIEGO CT
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-6500
Mailing Address - Country:US
Mailing Address - Phone:505-238-6420
Mailing Address - Fax:
Practice Address - Street 1:4686 CORRALES RD STE 4E
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-8658
Practice Address - Country:US
Practice Address - Phone:505-238-6420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-25
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0142491101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM92189873Medicaid