Healthcare Provider Details

I. General information

NPI: 1285107433
Provider Name (Legal Business Name): SAMANTHA HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6405 GATO RD
ANTHONY NM
88021-9299
US

IV. Provider business mailing address

6405 GATO RD
ANTHONY NM
88021-9299
US

V. Phone/Fax

Practice location:
  • Phone: 575-520-1931
  • Fax:
Mailing address:
  • Phone: 575-520-1931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number97358
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH0224861
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: