Healthcare Provider Details

I. General information

NPI: 1649777053
Provider Name (Legal Business Name): AMANDA JEAN GARCIA LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99B SUNRISE RD
PUEBLO OF ACOMA NM
87034
US

IV. Provider business mailing address

PO BOX 17
ACOMA NM
87034-0017
US

V. Phone/Fax

Practice location:
  • Phone: 505-414-1330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-CTL0195711
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: