Healthcare Provider Details

I. General information

NPI: 1558032318
Provider Name (Legal Business Name): GERIANNE DALYNN ONTIVEROS LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2021
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W 4TH ST
PORTALES NM
88130-6306
US

IV. Provider business mailing address

1814 S AVENUE A
PORTALES NM
88130-7335
US

V. Phone/Fax

Practice location:
  • Phone: 575-777-2311
  • Fax:
Mailing address:
  • Phone: 575-777-2311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-CTL0219161
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: