Provider Demographics
NPI:1942531942
Name:LANDE, LISA (PHD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LANDE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3225 CALLE CELESTIAL
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506-1213
Mailing Address - Country:US
Mailing Address - Phone:505-980-1990
Mailing Address - Fax:
Practice Address - Street 1:720 E HACIENDA ST
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2523
Practice Address - Country:US
Practice Address - Phone:505-753-6769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1114103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist