Healthcare Provider Details

I. General information

NPI: 1912316308
Provider Name (Legal Business Name): A PLACE OF HEALING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 WYATT DR STE 5
LAS CRUCES NM
88005-2960
US

IV. Provider business mailing address

5065 COMANCHE TRL
LAS CRUCES NM
88012-7376
US

V. Phone/Fax

Practice location:
  • Phone: 575-644-9209
  • Fax: 575-647-5050
Mailing address:
  • Phone: 575-644-9209
  • Fax: 575-647-5050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0116921
License Number StateNM

VIII. Authorized Official

Name: AMY LYN TREVINO
Title or Position: PROVIDER/OPERATOR
Credential: ED.S, LPCC
Phone: 57546449209