Healthcare Provider Details

I. General information

NPI: 1982321311
Provider Name (Legal Business Name): DE LA LUZ CREATIVE GUIDANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 10/26/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 KIVA RD
MIMBRES NM
88049
US

IV. Provider business mailing address

PO BOX 511
MIMBRES NM
88049-0511
US

V. Phone/Fax

Practice location:
  • Phone: 575-740-1562
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: FERNANDO ORTIZ
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 575-707-8150