Healthcare Provider Details

I. General information

NPI: 1407566847
Provider Name (Legal Business Name): CYNTHIA L WHITE LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 11/28/2022
Certification Date: 11/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2356 FOX RD STE 300
SANTA FE NM
87507-7294
US

IV. Provider business mailing address

PO BOX 401
TESUQUE NM
87574-0401
US

V. Phone/Fax

Practice location:
  • Phone: 505-927-2052
  • Fax:
Mailing address:
  • Phone: 505-927-2052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCTB-2022-0823
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: