Healthcare Provider Details

I. General information

NPI: 1497944532
Provider Name (Legal Business Name): MIGUEL HUMBERTO LARA M.ED, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6621 DONIPHAN DR STE G
CANUTILLO TX
79835-5005
US

IV. Provider business mailing address

6621 DONIPHAN DR STE G
CANUTILLO TX
79835-5005
US

V. Phone/Fax

Practice location:
  • Phone: 915-877-5100
  • Fax: 915-877-5107
Mailing address:
  • Phone: 915-877-5100
  • Fax: 915-877-5107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0107171
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: