Provider Demographics
NPI:1760715916
Name:MARTIN, LISA G (LMHC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:G
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255A S CAMINO DEL PUEBLO
Mailing Address - Street 2:
Mailing Address - City:BERNALILLO
Mailing Address - State:NM
Mailing Address - Zip Code:87004-5973
Mailing Address - Country:US
Mailing Address - Phone:505-586-7235
Mailing Address - Fax:505-867-2357
Practice Address - Street 1:255A S CAMINO DEL PUEBLO
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004-5973
Practice Address - Country:US
Practice Address - Phone:505-586-7235
Practice Address - Fax:505-867-2357
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-04
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0122981101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health