Healthcare Provider Details

I. General information

NPI: 1669831053
Provider Name (Legal Business Name): MELINDA MONCAYO LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 BROADWAY BLVD NE 401
ALBUQUERQUE NM
87102-2360
US

IV. Provider business mailing address

10509 ARVILLA AVE NE
ALBUQUERQUE NM
87111-5003
US

V. Phone/Fax

Practice location:
  • Phone: 505-342-5488
  • Fax:
Mailing address:
  • Phone: 505-379-0354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberM-09823
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: