Provider Demographics
NPI:1306175518
Name:SJOSTRAND, TISHA MARIE (LMHC, LPN)
Entity type:Individual
Prefix:
First Name:TISHA
Middle Name:MARIE
Last Name:SJOSTRAND
Suffix:
Gender:F
Credentials:LMHC, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2126 PAM Y EUTILIA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-3257
Mailing Address - Country:US
Mailing Address - Phone:505-699-6751
Mailing Address - Fax:
Practice Address - Street 1:2126 PAM Y EUTILIA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-3257
Practice Address - Country:US
Practice Address - Phone:505-699-6751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0104951101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health