Healthcare Provider Details

I. General information

NPI: 1922812692
Provider Name (Legal Business Name): ELLEN MARIE VEGA LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2025
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S COPPER ST
DEMING NM
88030-3610
US

IV. Provider business mailing address

1311 N GRANT ST STE A
SILVER CITY NM
88061-5134
US

V. Phone/Fax

Practice location:
  • Phone: 575-590-8886
  • Fax: 575-546-4362
Mailing address:
  • Phone: 575-388-1447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2025-0038
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: