Healthcare Provider Details

I. General information

NPI: 1487941233
Provider Name (Legal Business Name): MRS. MISTY D BELANGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W 21ST ST
CLOVIS NM
88101-4087
US

IV. Provider business mailing address

1350 HILLRISE CIR
LAS CRUCES NM
88011-4759
US

V. Phone/Fax

Practice location:
  • Phone: 575-288-1881
  • Fax: 575-288-1889
Mailing address:
  • Phone: 575-288-1881
  • Fax: 575-288-1889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: