Healthcare Provider Details

I. General information

NPI: 1164741534
Provider Name (Legal Business Name): MELYNDA DENICE MADRID LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 07/19/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10408 CALLE ALMA NW
ALBUQUERQUE NM
87114-1366
US

IV. Provider business mailing address

PO BOX 67638
ALBUQUERQUE NM
87193-7638
US

V. Phone/Fax

Practice location:
  • Phone: 505-306-2257
  • Fax: 833-837-3627
Mailing address:
  • Phone: 505-306-2257
  • Fax: 833-837-3627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0132101
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: