Provider Demographics
NPI:1750514626
Name:DWORAK, LINDSAY NICOLE (LMFT)
Entity type:Individual
Prefix:
First Name:LINDSAY
Middle Name:NICOLE
Last Name:DWORAK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:LINDSAY
Other - Middle Name:NICOLE
Other - Last Name:FELLOWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:3 LATIR CT
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-2192
Mailing Address - Country:US
Mailing Address - Phone:575-693-6132
Mailing Address - Fax:
Practice Address - Street 1:3 LATIR CT
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-2192
Practice Address - Country:US
Practice Address - Phone:575-693-6132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCMF0167591106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM58455779Medicaid