=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134105380
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRENT LAMAR JOHN L.P.C.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2005
-----------------------------------------------------
Last Update Date | 01/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4011 BARBARA LOOP SE STE 206A
-----------------------------------------------------
City | RIO RANCHO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87124-1041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-796-2356
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 SUGAR RIDGE LOOP SE
-----------------------------------------------------
City | RIO RANCHO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87124-4312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-796-2356
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | CCMH013001
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------