Provider Demographics
NPI:1629657747
Name:SPELLBRING, ANNALISSA (LSAA)
Entity Type:Individual
Prefix:
First Name:ANNALISSA
Middle Name:
Last Name:SPELLBRING
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 W ARRINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8513
Mailing Address - Country:US
Mailing Address - Phone:505-564-3733
Mailing Address - Fax:
Practice Address - Street 1:228 N SCHWARTZ AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5547
Practice Address - Country:US
Practice Address - Phone:505-327-4584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0216641101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMCSA0216641OtherLICENSE