Provider Demographics
NPI:1891347845
Name:KURKJIAN, LISA SMITH
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:SMITH
Last Name:KURKJIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1371
Mailing Address - Street 2:
Mailing Address - City:RANCHOS DE TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87557-1371
Mailing Address - Country:US
Mailing Address - Phone:575-613-3085
Mailing Address - Fax:
Practice Address - Street 1:1337 GUSDORF RD STE G
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6297
Practice Address - Country:US
Practice Address - Phone:575-758-4337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCF6785235Z00000X
NMSLP7686235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist