Healthcare Provider Details

I. General information

NPI: 1730395732
Provider Name (Legal Business Name): OMAR NATIVIDAD REYES M.A. LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 N ROADRUNNER PKWY APT. 2404
LAS CRUCES NM
88011-8094
US

IV. Provider business mailing address

251 N ROADRUNNER PKWY APT. 2404
LAS CRUCES NM
88011-8094
US

V. Phone/Fax

Practice location:
  • Phone: 505-496-7884
  • Fax:
Mailing address:
  • Phone: 505-496-7884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0087741
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: