Provider Demographics
NPI:1881992311
Name:LISA DYKES-HARRELL, LLC
Entity type:Organization
Organization Name:LISA DYKES-HARRELL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DYKES-HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:575-749-3736
Mailing Address - Street 1:187 NM 88
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130
Mailing Address - Country:US
Mailing Address - Phone:575-749-3736
Mailing Address - Fax:575-226-6892
Practice Address - Street 1:100 S AVE A
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-5917
Practice Address - Country:US
Practice Address - Phone:575-749-3736
Practice Address - Fax:575-226-6892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM005790101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM04850041Medicaid
NM11783765OtherCAQH
NM1316956923OtherSOLE PROPRIETER NPI 1316956923