Provider Demographics
NPI:1710387105
Name:LIZA C MERMELSTEIN PHD LLC
Entity type:Organization
Organization Name:LIZA C MERMELSTEIN PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LIZA
Authorized Official - Middle Name:CHYTILO
Authorized Official - Last Name:MERMELSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:607-768-9640
Mailing Address - Street 1:9426 INDIAN SCHOOL RD NE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-2886
Mailing Address - Country:US
Mailing Address - Phone:505-345-6100
Mailing Address - Fax:505-345-4531
Practice Address - Street 1:9426 INDIAN SCHOOL RD NE
Practice Address - Street 2:SUITE 1
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2886
Practice Address - Country:US
Practice Address - Phone:505-345-6100
Practice Address - Fax:505-345-4531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1347103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty