Provider Demographics
NPI:1639254154
Name:WOOLDRIDGE, LISA DIAN (LPCC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIAN
Last Name:WOOLDRIDGE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:DIAN
Other - Last Name:WARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:411 SAINT MICHAELS DR STE 2
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7655
Mailing Address - Country:US
Mailing Address - Phone:505-690-8322
Mailing Address - Fax:
Practice Address - Street 1:411 SAINT MICHAELS DR STE 2
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7655
Practice Address - Country:US
Practice Address - Phone:505-690-8322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0065012101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional