Healthcare Provider Details

I. General information

NPI: 1467111302
Provider Name (Legal Business Name): IDA LUPE MONTES-SALCEDO LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 12/08/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 RUIDOSO WARRIOR DR
RUIDOSO NM
88345
US

IV. Provider business mailing address

143 EL PASO RD
RUIDOSO NM
88345-6033
US

V. Phone/Fax

Practice location:
  • Phone: 575-630-7974
  • Fax:
Mailing address:
  • Phone: 575-686-8297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH0207531
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: