Healthcare Provider Details

I. General information

NPI: 1467318501
Provider Name (Legal Business Name): ALICIA CANCINO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2026
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 W APACHE ST
FARMINGTON NM
87401-5835
US

IV. Provider business mailing address

806 MIRABEL ST
FARMINGTON NM
87401-4052
US

V. Phone/Fax

Practice location:
  • Phone: 505-325-5321
  • Fax:
Mailing address:
  • Phone: 505-325-5321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2025-0960
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: