Healthcare Provider Details

I. General information

NPI: 1881035319
Provider Name (Legal Business Name): MANDY JO RENTERIA LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 07/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7613
US

IV. Provider business mailing address

8300 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7613
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-2554
  • Fax: 505-291-2552
Mailing address:
  • Phone: 505-291-2554
  • Fax: 505-291-2552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0152791
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: