Healthcare Provider Details

I. General information

NPI: 1669792008
Provider Name (Legal Business Name): JANICE L CHUA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 01/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 PASEO DEL PUEBLO SUR
TAOS NM
87571-5922
US

IV. Provider business mailing address

PO BOX 28220
SANTA FE NM
87592-8220
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-7263
  • Fax:
Mailing address:
  • Phone: 505-471-5006
  • Fax: 505-820-9220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0146101
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: