Basic Information
| Provider Information | |||||||||
| NPI: | 1962514349 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | BAEZA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PHS PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
| FaxNumber: | 5059235354 | ||||||||
| Practice Location | |||||||||
| Address1: | 8300 CONSTITUTION AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052912500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 09/28/2018 | ||||||||
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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 | 2084P0800X | T2002014678 | MO | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | MD2018-0781 | NM | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.