MEDICARE: MAYA S FERNANDEZ LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	0154951	NM

General Provider Information

NPI Number	:	1942548714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYA S FERNANDEZ LMHC

Provider Business Mailing Address
First Line	:	538 REGINA RD NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87105-1530
Country	:	US
Telephone Number	:	505-203-8631
Fax Number	:	505-898-7288

Provider Business Practice Location Address
First Line	:	6666 4TH ST NW
Second Line	:
City	:	LOS RANCHOS
State	:	NM
Zip	:	87107-6144
Country	:	US
Telephone Number	:	505-230-8631
Fax Number	:	505-898-7288

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2013
Last Update Date	:	01/29/2013

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