Healthcare Provider Details

I. General information

NPI: 1871405886
Provider Name (Legal Business Name): JEANETTE DIAZ LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6713 4TH ST NW
LOS RANCHOS NM
87107-6114
US

IV. Provider business mailing address

6411 CANAVIO PL NW
ALBUQUERQUE NM
87120-7052
US

V. Phone/Fax

Practice location:
  • Phone: 505-718-2119
  • Fax: 505-944-1953
Mailing address:
  • Phone: 505-718-2119
  • Fax: 505-944-1953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2024-0241
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: