Healthcare Provider Details

I. General information

NPI: 1356034771
Provider Name (Legal Business Name): NICHOLE MOHR LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 WYATT DR STE 9
LAS CRUCES NM
88005-2962
US

IV. Provider business mailing address

3200 32ND STREET BYP
SILVER CITY NM
88061-7802
US

V. Phone/Fax

Practice location:
  • Phone: 575-495-7391
  • Fax:
Mailing address:
  • Phone: 575-495-7391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCBT-2023-0396
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: