1740443738 NPI number — SUSAN TANYA LEHERISSEY LMT

Table of content: SUSAN TANYA LEHERISSEY LMT (NPI 1740443738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740443738 NPI number — SUSAN TANYA LEHERISSEY LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEHERISSEY
Provider First Name:
SUSAN
Provider Middle Name:
TANYA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMT
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:
1740443738
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LLANO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87543-0009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-587-2063
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
37 UPPER LLANO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LLANO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-587-2063
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/09/2008

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: 174400000X , with the licence number:  1790 , 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)

  • Identifier: 1790 . This is a "LICENSE NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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