=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164741534
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELYNDA DENICE MADRID LPCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2010
-----------------------------------------------------
Last Update Date | 07/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10408 CALLE ALMA NW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87114-1366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-306-2257
-----------------------------------------------------
Fax | 833-837-3627
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 67638
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87193-7638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-306-2257
-----------------------------------------------------
Fax | 833-837-3627
-----------------------------------------------------
=====================================================
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 | CCMH0132101
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------