Provider Demographics
NPI:1437481207
Name:MACOMBER, PATTI H (LISW)
Entity Type:Individual
Prefix:
First Name:PATTI
Middle Name:H
Last Name:MACOMBER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 CENTRAL AVE SE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3460
Mailing Address - Country:US
Mailing Address - Phone:505-268-1125
Mailing Address - Fax:
Practice Address - Street 1:202 CENTRAL AVE SE
Practice Address - Street 2:SUITE 300
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3460
Practice Address - Country:US
Practice Address - Phone:505-268-1125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-05166101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMM1919Medicaid