Healthcare Provider Details

I. General information

NPI: 1346532199
Provider Name (Legal Business Name): LUCIA DARLACH PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2011
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 UNSER BLVD NW SW MESA CLINIC
ALBUQUERQUE NM
87121-1927
US

IV. Provider business mailing address

704 2ND ST SW
ALBUQUERQUE NM
87102-4119
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-4814
  • Fax:
Mailing address:
  • Phone: 773-682-0535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number071007548
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number071007548
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1266
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: