Healthcare Provider Details

I. General information

NPI: 1740513696
Provider Name (Legal Business Name): MELISSA ANN TOLEDO- ONTIVEROS M.A., M.C.J, M.P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA ANN PORTILLOS

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 PERKINS DR
LAS CRUCES NM
88005-3758
US

IV. Provider business mailing address

1430 E MESA AVE APT 18
LAS CRUCES NM
88001-5786
US

V. Phone/Fax

Practice location:
  • Phone: 505-977-9722
  • Fax:
Mailing address:
  • Phone: 505-977-9722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0129951
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: