Provider Demographics
NPI:1679775076
Name:MERMELSTEIN, LIZA CHYTILO (PHD)
Entity type:Individual
Prefix:
First Name:LIZA
Middle Name:CHYTILO
Last Name:MERMELSTEIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1347103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical