Healthcare Provider Details

I. General information

NPI: 1346010105
Provider Name (Legal Business Name): LA LUZ MENTAL WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 01/03/2024
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4245 JUAN TABO BLVD NE SUITE 220
ALBUQUERQUE NM
87110-8712
US

IV. Provider business mailing address

4801 LANG AVE NE STE 110
ALBUQUERQUE NM
87109-4475
US

V. Phone/Fax

Practice location:
  • Phone: 505-321-8205
  • Fax:
Mailing address:
  • Phone: 505-321-8205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: CHRISTYN M SMALL
Title or Position: OWNER
Credential: LPCC
Phone: 505-321-8205