Healthcare Provider Details

I. General information

NPI: 1114690443
Provider Name (Legal Business Name): VISTA CLARA COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 RT 66 W SUITE F
MORIARTY NM
87035
US

IV. Provider business mailing address

PO BOX 2732
MORIARTY NM
87035-2732
US

V. Phone/Fax

Practice location:
  • Phone: 505-433-8822
  • Fax:
Mailing address:
  • Phone: 505-433-8822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: SARA SADIE LOMBARDI
Title or Position: OWNER/MANAGER
Credential: MS, LPCC
Phone: 505-433-8822