Healthcare Provider Details

I. General information

NPI: 1316267073
Provider Name (Legal Business Name): LIDA VALENCIA, PSR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 09/14/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4730 BECKNER ROAD
SANTA FE NM
87507
US

IV. Provider business mailing address

4730 BECKNER ROAD
SANTA FE NM
87507
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-4500
  • Fax: 505-443-8313
Mailing address:
  • Phone: 505-989-4500
  • Fax: 505-443-8313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberTCTL0211691
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: