Healthcare Provider Details

I. General information

NPI: 1487392940
Provider Name (Legal Business Name): LYTE PSYCHIATRY NEW MEXICO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2022
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E GRAND AVE # 8
CLOVIS NM
88101-7549
US

IV. Provider business mailing address

120 E GRAND AVE # 8
CLOVIS NM
88101-7549
US

V. Phone/Fax

Practice location:
  • Phone: 469-733-0848
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. OLUWATOYIN AWE
Title or Position: OWNER
Credential:
Phone: 817-810-6649