Healthcare Provider Details

I. General information

NPI: 1801310693
Provider Name (Legal Business Name): SONIA DANIELLA MORAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 08/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S MAIN ST STE 249
LAS CRUCES NM
88001-1243
US

IV. Provider business mailing address

505 S MAIN ST STE 249
LAS CRUCES NM
88001-1243
US

V. Phone/Fax

Practice location:
  • Phone: 575-527-5884
  • Fax: 575-527-5886
Mailing address:
  • Phone: 575-527-5886
  • Fax: 575-527-5886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number375230
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: