Healthcare Provider Details

I. General information

NPI: 1245692102
Provider Name (Legal Business Name): LA LUZ PROVIDER AGENCY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 FRANKLIN AVE UNIT 6
SANTA FE NM
87501-3617
US

IV. Provider business mailing address

PO BOX 34091
SANTA FE NM
87594-4091
US

V. Phone/Fax

Practice location:
  • Phone: 505-660-3484
  • Fax:
Mailing address:
  • Phone: 505-660-3484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: CHERYL SCIACCA
Title or Position: CO-OWNER
Credential: LPCC
Phone: 505-660-3484