Healthcare Provider Details

I. General information

NPI: 1780432443
Provider Name (Legal Business Name): ELISA ROMERO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2024
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6666 4TH ST NW STE C-1
LOS RANCHOS NM
87107-6144
US

IV. Provider business mailing address

6666 4TH ST NW STE C-1
LOS RANCHOS NM
87107-6144
US

V. Phone/Fax

Practice location:
  • Phone: 505-705-1125
  • Fax:
Mailing address:
  • Phone: 505-705-1125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2024-0040
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: