Healthcare Provider Details

I. General information

NPI: 1942545496
Provider Name (Legal Business Name): CYNTHIA LENA CHILA LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 SPRUCE ST STE C
ESPANOLA NM
87532-3455
US

IV. Provider business mailing address

835 SPRUCE ST STE C
ESPANOLA NM
87532-3455
US

V. Phone/Fax

Practice location:
  • Phone: 505-747-7400
  • Fax: 505-747-7403
Mailing address:
  • Phone: 505-747-7400
  • Fax: 505-747-7403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0149331
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: