Provider Demographics
NPI:1417085796
Name:MAVES, LISA C (MA, LPC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:C
Last Name:MAVES
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5725 QUAY DR NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-5173
Mailing Address - Country:US
Mailing Address - Phone:505-771-9383
Mailing Address - Fax:505-834-7903
Practice Address - Street 1:110 SHEEP SPRINGS
Practice Address - Street 2:
Practice Address - City:JEMEZ PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87024
Practice Address - Country:US
Practice Address - Phone:505-834-3059
Practice Address - Fax:505-834-7093
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0070821101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health