Healthcare Provider Details

I. General information

NPI: 1942548714
Provider Name (Legal Business Name): MAYA S FERNANDEZ LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2013
Last Update Date: 01/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6666 4TH ST NW
LOS RANCHOS NM
87107-6144
US

IV. Provider business mailing address

538 REGINA RD NW
ALBUQUERQUE NM
87105-1530
US

V. Phone/Fax

Practice location:
  • Phone: 505-230-8631
  • Fax: 505-898-7288
Mailing address:
  • Phone: 505-203-8631
  • Fax: 505-898-7288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0154951
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: