Provider Demographics
NPI:1144535337
Name:KING, LISA MARIE (MA,LADAC)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:KING
Suffix:
Gender:F
Credentials:MA,LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 MEDICINE HORSE DR.
Mailing Address - Street 2:86 MEDICINE HORSE DR.
Mailing Address - City:CANONCITO
Mailing Address - State:NM
Mailing Address - Zip Code:87026-3368
Mailing Address - Country:US
Mailing Address - Phone:505-908-2571
Mailing Address - Fax:
Practice Address - Street 1:86 MEDICINE HORSE DR.
Practice Address - Street 2:86 MEDICINE HORSE DR.
Practice Address - City:CANONCITO
Practice Address - State:NM
Practice Address - Zip Code:87026
Practice Address - Country:US
Practice Address - Phone:505-908-2571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM702824101YA0400X
NM0131581101YA0400X
NM01311581101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)