Provider Demographics
NPI:1689861916
Name:MESIBOV, GEORGINA (LPCC)
Entity Type:Individual
Prefix:MS
First Name:GEORGINA
Middle Name:
Last Name:MESIBOV
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:GEORGINA
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCC
Mailing Address - Street 1:4715 QUEMAZON
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544
Mailing Address - Country:US
Mailing Address - Phone:505-695-0233
Mailing Address - Fax:505-661-9637
Practice Address - Street 1:118 CENTRAL PARK SQUARE
Practice Address - Street 2:
Practice Address - City:LAS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544
Practice Address - Country:US
Practice Address - Phone:505-695-0233
Practice Address - Fax:505-661-9637
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM006109101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health