Healthcare Provider Details

I. General information

NPI: 1770329294
Provider Name (Legal Business Name): LUMINA MENTAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2024
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10815 CHICOBUSH DR NW
ALBUQUERQUE NM
87114-5550
US

IV. Provider business mailing address

PO BOX 67133
ALBUQUERQUE NM
87193-7133
US

V. Phone/Fax

Practice location:
  • Phone: 505-289-3984
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: REYNA AMANDA GARCIA
Title or Position: OWNER/CLINICIAN
Credential: LPCC, NCC
Phone: 505-289-3984