Healthcare Provider Details

I. General information

NPI: 1285099556
Provider Name (Legal Business Name): VIRGINIA LONGORIA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2015
Last Update Date: 07/17/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2488 CALLE DE GUADALUPE
MESILLA NM
88046-0594
US

IV. Provider business mailing address

PO BOX 370
HATCH NM
87937-0370
US

V. Phone/Fax

Practice location:
  • Phone: 575-249-5029
  • Fax: 575-249-3515
Mailing address:
  • Phone: 575-267-3280
  • Fax: 575-267-1747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1492
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: