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General NPI Number Information
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NPI Number | 1558032318
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Entity Type | Individual
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Provider Name | GERIANNE DALYNN ONTIVEROS LMHC
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Gender | Female
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Dates
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Enumeration Date | 09/22/2021
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Last Update Date | 09/22/2021
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Provider Practice Location Address
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Address Line | 101 W 4TH ST
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City | PORTALES
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State | NM
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Zip | 88130-6306
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Country | US
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Telephone | 575-777-2311
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Fax |
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Provider Business Mailing Address
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Address Line | 1814 S AVENUE A
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City | PORTALES
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State | NM
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Zip | 88130-7335
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Country | US
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Telephone | 575-777-2311
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | T-CTL0219161
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License Number State | NM
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