Healthcare Provider Details

I. General information

NPI: 1235014044
Provider Name (Legal Business Name): JONATHAN WALLACH LPCC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2025
Last Update Date: 08/11/2025
Certification Date: 08/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 MARQUEZ PL STE C
SANTA FE NM
87505-1694
US

IV. Provider business mailing address

13 LOMA SERENA
SANTA FE NM
87506-7531
US

V. Phone/Fax

Practice location:
  • Phone: 780-822-6795
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MONA HOOVER
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 217-621-6595