Provider Demographics
NPI:1285723395
Name:CELOSSE, LISA (LPCC, LMFT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CELOSSE
Suffix:
Gender:F
Credentials:LPCC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:CHIMAYO
Mailing Address - State:NM
Mailing Address - Zip Code:87522-0250
Mailing Address - Country:US
Mailing Address - Phone:505-720-9167
Mailing Address - Fax:
Practice Address - Street 1:2019 GALISTEO, N-10D
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-720-9167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0091031106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00JV87OtherBLUECROSS BLUESHIELD
NM21353336Medicaid