Healthcare Provider Details

I. General information

NPI: 1679293559
Provider Name (Legal Business Name): ANGELA R JOHNSON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 S 1ST ST
TUCUMCARI NM
88401-2707
US

IV. Provider business mailing address

325 S 1ST ST
TUCUMCARI NM
88401-2707
US

V. Phone/Fax

Practice location:
  • Phone: 575-282-2222
  • Fax: 575-282-2224
Mailing address:
  • Phone: 575-282-2222
  • Fax: 575-282-2224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2024-0166
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: