1023395126 NPI number — LISSI WANDEMBURG OVERCAST M.A.

Table of content: LISSI WANDEMBURG OVERCAST M.A. (NPI 1023395126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023395126 NPI number — LISSI WANDEMBURG OVERCAST M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OVERCAST
Provider First Name:
LISSI
Provider Middle Name:
WANDEMBURG
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023395126
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 PERKINS DR STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88005-3248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-526-6682
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1681 HICKORY LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88005-6587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-647-3773
Provider Business Practice Location Address Fax Number:
575-647-3777
Provider Enumeration Date:
11/03/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP5152 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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