Provider Demographics
NPI:1255812624
Name:TABISULA, MISTY
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:TABISULA
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 1:320 OSUNA RD NE STE H4
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5955
Mailing Address - Country:US
Mailing Address - Phone:505-345-2778
Mailing Address - Fax:
Practice Address - Street 1:320 OSUNA RD NE STE H4
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-5955
Practice Address - Country:US
Practice Address - Phone:505-345-2778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008435101Y00000X
GAMFT001348106H00000X
NMCMF0197861106H00000X
NMCCMH0201901101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor