Healthcare Provider Details

I. General information

NPI: 1205545662
Provider Name (Legal Business Name): GRACIELA PONCE LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRACIELA TORRES

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18420 S HIGHWAY 28
LA MESA NM
88044-9605
US

IV. Provider business mailing address

385 CALLE DE ALEGRA STE A
LAS CRUCES NM
88005-3423
US

V. Phone/Fax

Practice location:
  • Phone: 575-233-3830
  • Fax: 575-233-4542
Mailing address:
  • Phone: 575-526-1105
  • Fax: 575-524-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH0204121
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCTB-2024-0609
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: