Healthcare Provider Details

I. General information

NPI: 1760116925
Provider Name (Legal Business Name): ALYSSA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2022
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1194 SAINT FRANCIS LN UNIT 3
TAOS NM
87571-8240
US

IV. Provider business mailing address

PO BOX 3100
RANCHOS DE TAOS NM
87557-3100
US

V. Phone/Fax

Practice location:
  • Phone: 575-779-2828
  • Fax:
Mailing address:
  • Phone: 575-613-3144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCTB-2025-0155
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: