Healthcare Provider Details

I. General information

NPI: 1790369528
Provider Name (Legal Business Name): AIMEE E DALE-LUCIUS LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 10/20/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4730 BECKNER ROAD
SANTA FE NM
87507-3691
US

IV. Provider business mailing address

4730 BECKNER ROAD
SANTA FE NM
87507-3691
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 NumberLPCC.0017449
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCTB-2023-0438
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: