Provider Demographics
NPI:1174658819
Name:ECKELKAMP, LISA (MS, CCC-SLP, BCBA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ECKELKAMP
Suffix:
Gender:F
Credentials:MS, CCC-SLP, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2674
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048
Mailing Address - Country:US
Mailing Address - Phone:505-249-8714
Mailing Address - Fax:
Practice Address - Street 1:5 MAES RD
Practice Address - Street 2:B
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048
Practice Address - Country:US
Practice Address - Phone:505-249-8714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM11623536103K00000X
NM3167235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM16939743Medicaid