Provider Demographics
NPI:1669724043
Name:BARTLEY, LISA KADEL
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:KADEL
Last Name:BARTLEY
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 1:1721C CAMINO DOS ANTONIOS # 15
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-3322
Mailing Address - Country:US
Mailing Address - Phone:505-231-5152
Mailing Address - Fax:
Practice Address - Street 1:711 S SAINT FRANCIS DR
Practice Address - Street 2:#2
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3082
Practice Address - Country:US
Practice Address - Phone:505-231-5152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0165761101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health