Basic Information
| Provider Information | |||||||||
| NPI: | 1831756683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUJAN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3192 ASHKIRK LOOP SE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871243625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059164729 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2221 RIO GRANDE BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871042529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058301871 | ||||||||
| FaxNumber: | 5058300040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2019 | ||||||||
| LastUpdateDate: | 05/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | NA | 01 | DO NOT HAVE NUMBER | OTHER |